Ischemic heart disease: what is it, what treatments?
Ischemic heart disease is a serious heart condition that can have serious consequences: heart attack, sudden death Therefore, it requires urgent medical attention. How does it manifest itself? What are the treatments? We will talk to Dr. Florian Zores, a cardiologist.
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What is heart disease?
Heart disease is a heart attack responsible for a disturbance in the heart's functioning. Ischemia is a defect in the oxygenation of cells, usually secondary to a narrowing or occlusion of one or more arteries.
"Ischemic heart disease is therefore an alteration of heart function secondary to a defect in the oxygenation of the heart muscle cells (cardiomyocytes).
The decrease in oxygen supply to the heart cells leads to a total or partial loss of the heart muscle's (myocardium's) ability to contract and relax," explains cardiologist Dr. Florian Zores.
The narrowing of the coronary arteries, responsible for the reduction of blood flow and, consequently, of cardiac oxygenation, is generally secondary to coronary atherosclerosis; the narrowing (stenosis) is more or less diffuse, more or less sudden and more or less complete.
The complete interruption of the coronary circulation by a thrombus (clot), which leads to a prolonged ischemia, causes necrosis of the heart muscle: it is a myocardial infarction.
"Of all heart diseases, ischemic heart disease is the most common. It is considered to be responsible for half of all heart failures," says the cardiologist.
Chronic Ischemic Heart Disease
Chronic ischemic cardiopathy is the alteration of heart function secondary to diffuse and chronic damage to the coronary artery network and/or as a consequence of one or more myocardial infarctions.
It can be manifested by chest pain during exertion (angina) and/or by an alteration in heart muscle contraction (heart failure).
Ischemic heart disease of the stent
A stent is an arterial stent, a tubular metal device placed in an artery to keep it open, typically compared to a "spring.
To open an occluded or narrowed artery, an angioplasty (dilation of the artery) is performed with a balloon. The risk of this technique is that of restenosis (reappearance of the stenosis) more or less early.
Placement of a stent in a newly angioplastic artery significantly reduces the risk of restenosis.
Because it is foreign material, stents expose a greater risk of thrombus (clot) formation. Therefore, treatment is essential to reduce the risk of clotting in the months following the stenting procedure.
The stent is usually placed after a heart attack. More rarely, one or more stents may be implanted in cases of chronic coronary disease.
Bridge Ischemic Heart Disease
Coronary artery bypass surgery is a heart surgery procedure that consists of bypassing an occluded or severely narrowed coronary artery with another vessel, which allows for adequate irrigation of the heart muscle.
Bypass surgery can be performed with segments of arteries (chest arteries are used) or segments of veins (taken from the legs).
The procedure is performed after opening the chest at the sternum, either in a beating heart or in a stopped heart with extracorporeal circulation.
The number of shunts performed during the procedure (single, double, triple, etc...) depends on the number of affected arteries and the number of stenoses.
The average duration of surgery is one hour for each bypass. Bypasses are usually performed when damage to the coronary arteries is severe.
"The choice between bypass surgery or stent placement is the result of a discussion between cardiologists and surgeons and takes into account many parameters, including the number, location, and severity of coronary artery damage, heart function, and other conditions the patient may have," said Dr. Zores.
Tritroncular Ischemic Heart Disease
"The heart muscle is irrigated by three arteries: a right coronary artery and two 'left' coronary arteries (the anterior interventricular artery and the circumflex artery) that originate from a single artery (the common trunk)," explains Dr. Zores. Therefore, a tritrullary coronary lesion is a significant lesion in all three coronary arteries simultaneously.
"Coronary disease, which is responsible for ischemic heart disease, is in almost all cases secondary to atherosclerosis, that is, the invasion of the arterial walls by cholesterol, sugars, platelets, macrophages, lime, fibrinogen, etc." Dr. Zores summarizes.
The risk factors for atherosclerosis are well known. Some are not modifiable:
- A genetic predisposition: having a parent who has had a heart attack before age 55-60 increases the risk of having a heart attack.
- Men: Men are more affected
- Age: The risk of coronary disease increases with age.
- Other factors can be managed and must be controlled:
- Hypercholesterolemia (excess cholesterol in the blood)
- High blood pressure
- The sedentary lifestyle
"Several of these risk factors are, to a greater or lesser extent depending on the individual, the result of an unbalanced diet that is too rich in fats, sugars and proteins," explains Dr. Zores.
Ischemic heart disease can be expressed in different ways:
The most acute form is the occlusion of a coronary artery, which is responsible for stopping cardiac oxygenation and thus the necrosis of the heart muscle.
It is the heart attack. The symptoms are usually a pain in the center of the chest, of the type of vice, squeeze or intense pressure, which can radiate to the left arm and/or the jaw, sometimes associated with shortness of breath, palpitations or discomfort, which occurs suddenly and does not stop.
A pain that lasts more than 20 minutes should call 15.
If arteries are not occluded but narrowed, the decrease in blood supply is only symptomatic when an effort is made. Chest pain is similar to that of a heart attack, but only appears during exertion (physical activity, digestion, cold) and disappears when exertion stops.
It is angina pectoris or stress angina. A quick consultation with a physician is imperative.
Decreased oxygenation of the cells of the heart leads to a decreased ability of the myocardium to contract.
The pumping capacity of the heart is affected, and blood circulates less efficiently through the body.
This is called heart failure. The usual symptoms are grouped under the acronym EPOF: shortness of breath with little effort, rapid weight gain, edema in the calves and then in the legs or even thighs, unusual fatigue.
Finally, due to the lack of oxygen, the cells of the heart are more easily subjected to rhythm disorders.
The manifestation of ischemic heart disease can therefore be a serious heart rhythm disorder, responsible for sudden death.
"The diagnosis of angina pectoris and heart attack can be suspected as soon as the patient is questioned as to whether the condition is typical," explains Dr. Zores. "However, additional tests are usually needed to confirm the diagnosis and guide management," he adds.
The electrocardiogram (ECG) alone confirms the diagnosis of a heart attack. It is not always normal in the case of chronic ischemic heart disease, but it is rarely sufficient to confirm the existence of ischemia outside the context of the heart attack.
Cardiac ultrasound allows analysis of the heart's contraction to reveal a decrease in the heart's ability to contract, evoking heart failure, and/or the walls of the heart whose contraction is reduced due to ischemia. However, the test may be normal if ischemia only exists during exercise.
The stress test is an ECG recorded continuously while the patient is under physical strain.
The goal is to trigger ischemia during physical exertion, which will cause pain and changes in the ECG pattern.
Stress myocardial scintigraphy consists of the injection of a weakly radioactive product that will be fixed in the parts of the heart that are oxygenated.
If the tracer does not join, it means that the artery network is sick. The test is first performed after a stress test, then a second acquisition is made a few hours later, at rest.
The comparison of images at stress and at rest makes it possible to confirm the existence of ischemia or necrosis, and to specify the location and extent, which a simple stress test cannot do.
According to the same principle, stress echocardiography or stress echocardiography is an echocardiogram performed simultaneously with a strain or the injection of a product that stimulates the heart to imitate a strain.
The analysis of the movement of the walls and the intensity of the contractions then allows the suspicion of the existence of an ischemia, to specify the location and the extension of it.
Coronary angiography is the benchmark test for analyzing the anatomy of the coronary arteries. It allows visualization of the extent and extent of narrowing and occlusion. The possible treatment of these occlusions can be considered during the same exam.
Cardiac magnetic resonance allows a fine analysis of the heart's contraction and the visualization of the sequels of the infarct. The search for ischemia is also possible.
The coronary scanner makes it possible to study the coronary anatomy in the same way as coronary angiography, but in a less invasive way; but obviously no revascularization treatment can be performed during the scan.
Red blood cells carry oxygen. Anemia is the lack of red blood cells and is diagnosed by measuring the level of hemoglobin in the blood. The more severe the anemia and the faster it sets in, the greater the lack of oxygen at the cellular level.
Blood transfusion provides new red blood cells to ensure oxygen transport.
The hemoglobin levels at which transfusion is recommended in patients with ischemic heart disease are highly variable and depend on the rate of occurrence of the anemia (acute or chronic), the nature of the ischemic heart disease (myocardial infarction, heart failure, etc.), and the episode of care (surgery, resuscitation, etc.).
"The prevention of ischemic heart disease is actually the prevention of coronary disease. This prevention is based on the control and limitation of risk factors," explains Dr. Zores :
- No smoking. When it comes to heart disease, there is no such thing as a "little cigarette. One cigarette a day carries a risk of heart attack almost similar to that of a half-pack.
- Regular physical activity: at least 30 minutes of moderate physical activity (an intensity level that allows you to talk but not whistle or sing) 5 days a week.
- Eat a balanced diet avoiding excess saturated fat, sugar and salt.
- Avoiding overweight and obesity
- Treat, with medication if necessary, any high blood pressure, high cholesterol or diabetes that may be present.
"Treatment of a heart attack is an absolute emergency," insists Dr. Zores. It consists of opening the artery during a coronary angiography with a balloon (angioplasty) and placing a stent.
The later the revascularization is delayed, the greater the side effects on heart contraction.
Beyond six hours of ischemia, the chances of heart muscle recovery are considered infinitesimal. Apart from myocardial infarction, coronary revascularization is discussed.
Recent studies stress that pharmacological treatment is predominant and that revascularization, which brings little benefit in most cases, should be reserved for the most serious patients (severe angina, heart failure, common trunk damage).
This revascularization is based on one or more angioplasties or one or more bypasses. This is a specialist discussion.
The chronic treatment of ischemic cardiopathy is pharmacological:
- Low-dose aspirin helps thin the blood and reduce the risk of clogged artery thrombi.
- Statins slow down the formation of atheromatous plaques and therefore allow better blood circulation.
- The anti-isthmic treatments allow to control the intensity of the angina or even make it disappear. These are beta-blockers, calcium channel blockers or nitrate derivatives.
- Converting enzyme inhibitors (ACE inhibitors) can slow the decline of heart function secondary to ischemia.
"Any diabetes or high blood pressure will also be treated, of course," adds Dr. Zores. He continued, "Non-pharmacological management is essential for reducing the risk of recurrent myocardial infarction or for slowing the progression of coronary disease. :
- Quitting smoking is essential
- Regular and appropriate physical activity is essential.
- A balanced diet with a reduced consumption of sugar and fat is essential.
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