A 53-year-old man presents with recurrent chest pain that has gotten progressively worse over the last

several weeks. He says that approximately a year ago the pain would occasionally occur when he was mowing his yard but now the pain sometimes occurs while he is sitting in a chair at night reading a book. The pain which is localized over the sternum, lasts much longer now than it did a few months ago. What type of disease does this individual have at present ?

I. Ischemic heart disease

Coronary heart disease or Coronary artery disease. Definition: A group of closely related disorders caused by myocardial ischemia due to an imbalance between oxygen demand and supply by the blood.

Etiology of IHD
1. Reduced coronary blood flow (90% 0f cases) a- Disease of the coronary: mostly due to atherosclerosis associated with thrombosis or vasospasm. Other uncommon causes include emboli from IE, vasculitis, vasospasm, coronary ostial narrowing as in syphilis. b- severe tachycardia (shortening of diastole) C- Aortic valve disease as stenosis or regurge D- severe hypotension as in shock.

Etiology of IHD
2. Increased myocardial demand.eg tachycardia, myocardial hypertrophy. 3.Hypoxia due to diminished oxygen transport eg severe anemia, advanced lung disease, and cyanotic congenital heart disease.

Pathogenesis of ischemic injury:Hypoxia: is the most important factor leading to ATP depletion, increase cytosolic calcium and shift to anaerobic respiration resulting into either reversible cell injury (cloudy swelling and fatty change) or irreversible cell injury (necrosis)

Failure to remove waste products (metabolites) e.g., accumulation of metabolites may explain the pain of muscle ischemia.

Classification of ischemic heart disease

1. Angina pectoris. 2. Myocardial infarction. 3. Chronic ischemic heart disease with congestive heart failure. 4. Sudden cardiac death.

I.

ANGINA PECTORIS

A clinical syndrome characterized by intermittent or episodic chest pain or discomfort caused by:
transient and reversible myocardial ischemia which is not severe enough to cause death of myocardial muscles.

PAIN
crushing , squeezing, constricting or knife like. It may radiate to the back , neck or left arm.

Types of Angina pectoris

1- Stable (typical) angina. 2-Variant (Prinzmetal) angina. 3-Unstable angina.

Angina pectoris
Stable Angina
It is associated with chronic fixed atherosclerotic narrowing of the coronaries.

Unstable Angina
It is precipitated by fissuring or disruption of the fixed atherosclerotic plaque with superadded thrombosis or vasospasm but the lumen is still opened.

Variant Angina
It is associated with coronary artery spasm near an advanced atherosclerotic plaque .

No Myocardial Necrosis

II. MYOCARDIAL INFARCTION

Definition: Development of an area of coagulative necrosis of the cardiac muscle due to sudden complete occlusion of arterial supply with deficient collateral circulation.

MI - Types
Transmural
Full thickness

Sub-endocardial
Inner 1/3 to half of ventricular wall Decreased circulating blood volume( shock, Hypotension, Lysed thrombus)

Superimposed thrombus in atherosclerosis

Focal damage

Circumferential

Transmural infarct

Subendocardial infarct

MI- Microscopic features

One-day-old infarct Up to 3 days duration

wavy fibers
Neutrophilic infiltrate

coagulative necrosis

1 -2 weeks

>3 weeks

Scar Granulation tissue

III. CHRONIC ISCHEMIC HEART DISEASE

Definition: Development of progressive congestive heart failure in elderly patients with multivessel coronary atherosclerotic narrowing. Mechanism: It occurs due to post infarction cardiac decompensation that follows exhaustion of the hypertrophied viable myocardium.

 Morphology: *Enlarged heart due to hypertrophy and dilatation of all chambers. *Atherosclerotic coronary narrowing. *Multiple areas of fibrous scar due to healed myocardial infarction. *Thickened endocardium covered by thrombi

Clinical picture:
1. Progressive congestive heart failure in patients with previous attacks of angina &/ or MI. 2. Arrythmias are common. 3. Death caused by - Arrythmias - CHF. - Acute myocardial infarction

IV. SUDDEN CARDIAC DEATH

Definition: unexpected cardiac death within one hour of symptom onset.

Due to Fatal arrythmias especilally ventricular fibrillation

Mechanism: Lethal cardiac arrythmias especially ventricular fibrillation. Morphology: Complicated coronary atherosclerotic plaque recent or old MI or scarring.