Coronary Heart Disease

(syn: Ischemic Heart Disease)

Dr. Shahjahan Ahmed Chowdhury

Associate Professor
Department of Community Medicine
 Definition

Impairment of heart
function due to
inadequate blood flow
to the heart compared
to its needs, caused
by its obstructive
changes in the
coronary circulation to
the heart.
 Presentation of CHD

Angina pectoris of heart

myocardial infarction
irregularities of the heart
cardiac failure
sudden death
Measuring the burden of disease
1. Proportional mortality ratio
2. Loss of life expectancy
3. CHD incidence rate
4. Age-specific death rates
5. Prevalence rate
6. Case fatality rate
7. Measurement of risk factor levels
8. Medical care
 1. Proportional mortality ratio

The simplest of all measures;

The proportion of all deaths currently
attributed to it;
For e.g. CHD is responsible for about
30% of all deaths in male
25% of all deaths in female in
most western countries
 2. Loss of life expectancy

CHD cuts short the life expectancy;

By complete elimination of CV deaths, life
increases upto 3.4 yrs to 9.4 yrs in men
and even more for women.
 3. CHD incidence rate

This is the sum of fatal and non fatal

attack rates.
Due to different manifestations, accurate
incidence rate of CHD rates are difficult to
compute.
So, mortality rates are used as a crude
indicator of incidence.
 4. Age-specific death rates

Age specific rates are used during

aetiological analysis.
 5. Prevalence rate

The prevalence of CHD can be estimated

by cross- sectional surveys/studies.
 6. Case fatality rate

This is defined as the proportion of attacks

that are fatal within 28 days of onset.
7. Measurement of risk factor levels

These include measurement of levels of

cigarette smoking, blood pressure, alcohol
consumption and serum cholesterol in the
community.
 8. Medical care

Measurement of levels of medical care in

the community.
 Modern Epidemic

The WHO has declared CHD as modern

epidemic; it causes 25-30% of deaths in
most industrialized countries.

A disease that affects populations, not an

unavoidable attribute of ageing.
 Epidemicity
USA - 1920
UK - 1930
Developing countries
Geographical variations of CHD

World wide- 7.2 million deaths (12.2% of

all deaths)
Europe- highest mortality
SEAR- 2nd highest mortality
Bangladesh- WHO declared no. 1 priority
among NCDs
 Risk factors
I. Non modifiable Age- increasing age
Sex- male suffer more
Age
Male > 45 years
Sex Female > 55 years
Family history Family history
Genetic factors Very important
 II. Modifiable

High blood cholesterol

High blood pressure
Smoking
Obesity
Lack of physical activity
Diabetes
Stress
 Risk factors (cont.)
Hypertension
The BP is the single most useful test for
identifying risk for developing CHD.
Tobacco Smoking
Important cause of preventable death
1 in 5 CHD deaths attributable to smoking
Diabetes
50% of deaths related to DM is due to CHD
 Risk factors (cont.)
Inactivity
Sedentary person has more risk for
developing CHD then active
person.
Obesity
- Obese person has more risk for
developing CHD then non obese
person.
 Risk factors (cont.)
Abnormal Blood Lipids

LDL Cholesterol (low density lipoprotein)

HDL Cholesterol (high density lipoprotein)

Blood Lipid Classification
Cholesterol:
<200 mg/dl Desirable
200-
200-239 mg/dl Borderline high-
high-risk
>240 mg/dl High-
High-risk
HDL Cholesterol
<40 mg/dl Low
>60 mgl/dl High, negates one
risk factor
LDL Cholesterol
<100 mg/dl Desirable
100 129 mg/dl Above optimal
130-
130-159 mg/dL Borderline High
>160 mg/dl High Risk
 Signs and Symptoms
Chest None: This is referred to as silent
None Pain ischemia.
Chest pain: If coronary arteries cant
supply enough blood to meet the
oxygen demands of the heart, the
result may be chest pain called angina.
Signs &
Symptoms Shortness of breath: Some people may
not be aware they have CAD until they
develop symptoms of congestive heart
failure- extreme fatigue with exertion,
shortness of breath and swelling in
their feet and ankles.
Shortness Heart
Of Breath Attack Heart attack: Results when an artery to
the heart muscle becomes completely
blocked and the heart muscles fed by
that artery dies.
 Prevention of CHD

a. Population strategy
b. High risk strategy
c. Secondary prevention
 a. Population strategy

i. Prevention in the whole populations

ii. Primordial prevention in whole
populations
 a. Population strategy
CHD is primarily a mass disease.
Specific interventions-
1. Dietary changes
in fat intake, of dietary cholesterol, in complex
carbohydrate intake (vegetables, fruits, grains,
legumes etc.)
2. Smoking- goal smoke- free society
3. Blood Pressure
4. PA- regular physical activity should be part of
normal daily life.
 Primordial prevention
A novel approach to primary prevention
Prevents the emergence and spread of CHD risk
factors
The approach of prevention should be
multifactorial, aimed at controlling or modifying
as many risk factors as possible.
Aim should be to change the community as a
whole, not the individual subjects living in it.
This approach is applied in developing countries
in particular.
 Primordial prevention (cont.)
Several well-planned interventional trials-
1. The multiple risk factor intervention trails
(MRFIT)- in US
2. The Stanford Heart Disease Prevention
programme in California, &
3. The North Kerelia Project in Finland-
Have demonstrated that primary
prevention can achieve substantial
reduction in the incidence of CHD.
 High-risk strategy
i. Identifying risk- by means of simple
test, such as BP, serum cholesterol
measurement
ii. Specific advice- those identified
having high risk are motivated to take
positive actions ( BP- take treatment,
smoking habit- quit )
 High-risk strategy (cont.)
Several well planned High risk intervention
studies are

Oslo Heart Study

Lipids research clinics study
Have shown to reduce the CHD risk factors.
 Secondary prevention
Continuation of primary prevention
It forms an important part of an overall
strategy
The aim of secondary prevention is to
prevent the recurrence and progression of
CHD
It is a rapidly field expanding field with
research (e.g. drug trails, coronary
surgery, use of pace makers).
 Screening and Diagnosis

Electro- Stress Coronary

cardiogram Test Angiography
 Other tests include-
Blood tests: used to evaluate kidney and thyroid
function as well as to check cholesterol levels
and the presence of anemia.
Chest X-ray: shows the size of your heart and
whether there is fluid build up around the heart
and lungs.
Echocardiogram: shows a graphic outline of the
hearts movement
Ejection fraction (EF): determines how well your
heart pumps with each beat.
 Treatment

LDL-
LDL-C Diet & Life Drug
Levels Habits Therapy
<100 mg/dL Yes No

100-
100-129 Yes Clinical
mg/dL Judgment
>130 mg/dL Yes Yes
 Treatment for CHD
Physical Activity
prescribed by physician for patients with
CHD
When aerobic activity is appropriate,
activity that places moderate stress on
the cardio-respiratory system can be
included.
Weight Control
 Many people are able to manage
coronary artery disease with lifestyle
changes and medications.

Other people with severe coronary

artery disease may need angioplasty or
surgery.
 Diet Therapy of High Blood
Cholesterol
Soluble Fiber
10-20 g/day
Treatment (continued)

1) Stenting
a stent is introduced into a blood vessel on a balloon
catheter and advanced into the blocked area of the artery
the balloon is then inflated and causes the stent to expand
until it fits the inner wall of the vessel, conforming to
contours as needed
the balloon is then deflated and drawn back
The stent stays in place permanently, holding the vessel
open and improving the flow of blood.
 Treatment (continued)

2) Angioplasty
a balloon catheter is passed through the guiding catheter to the
area near the narrowing. A guide wire inside the balloon catheter is
then advanced through the artery until the tip is beyond the
narrowing.
the angioplasty catheter is moved over the guide wire until the
balloon is within the narrowed segment.
balloon is inflated, compressing the plaque against the artery wall
once plaque has been compressed and the artery has been
sufficiently opened, the balloon catheter will be deflated and
removed.
 Treatment (continued)

3) Bypass surgery

healthy blood vessel is removed from leg, arm or chest

blood vessel is used to create new blood flow path in your heart
the bypass graft enables blood to reach your heart by flowing
around (bypassing)
the blocked portion
of the diseased
artery. The increased
blood flow reduces
angina and the risk
of heart attack.
 Risk factor intervention trials
Framingham study- 1951
The Stanford Heart Disease prevention
Programme in California
The North Kerelia Project
MRFIT(The multiple risk factor
intervention trial) USA
Oslow diet/Smoking Intervention study
Lipid Research Clinics Study USA
Get regular medical checkups.
Control your blood pressure.
Check your cholesterol.
Dont smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.
Manage stress.