Silent myocardial ischemia

Cardiovascular

Clinicals - History

Fact Explanation
Chest pain Hypertension is one of the leading preventable causes of premature coronary heart disease and thereby death
Angina, a frequent complication of hypertensive heart disease,gives rise to chest pain, often described
a heaviness, pressure, and/or a squeezing
Radiating to the jaw, neck, upper back, or left arm. Provoked by physical or emotional exertion
Relieved with rest or with the use of sublingual nitroglycerin
Chest pain
Hypertension is one of the leading preventable causes of premature coronary heart disease and thereby death
Angina, a frequent complication of hypertensive heart disease,gives rise to chest pain, often described
a heaviness, pressure, and/or a squeezing
Radiating to the jaw, neck, upper back, or left arm. Provoked by physical or emotional exertion
Relieved with rest or with the use of sublingual nitroglycerin
Symptoms of heart failure: orthopnea,paroxysmal nocturnal dyspnea, fatigue,ankle swelling With time, left ventricular hypertrophy, increasing vascular and ventricular tension ultimately lead to heart failure Symptoms of heart failure: orthopnea,paroxysmal nocturnal dyspnea, fatigue,ankle swelling
With time, left ventricular hypertrophy, increasing vascular and ventricular tension ultimately lead to heart failure
Past history of hypertension Hypertension is a major independent risk factor for heart diseases. Past history of hypertension
Hypertension is a major independent risk factor for heart diseases.
Past history of stroke Patients with hypertensive heart diseases may have other associated complications of hypertension such as strokes.
It has been reported that a fall of 10 - 20 mmHg in systolic pressure maintained for 5 years could reduce the risks of stroke by40%
Past history of stroke
Patients with hypertensive heart diseases may have other associated complications of hypertension such as strokes.
It has been reported that a fall of 10 - 20 mmHg in systolic pressure maintained for 5 years could reduce the risks of stroke by40%
History of renal failure Patients with hypertensive heart diseases may have other associated complications of hypertension such as renal failure. History of renal failure
Patients with hypertensive heart diseases may have other associated complications of hypertension such as renal failure.
Palpitations, Near or total syncope Patients with hypertension are more prone to get arrhythmia. Palpitations, Near or total syncope
Patients with hypertension are more prone to get arrhythmia.
Obesity, less exercise Although the main risk factor for hypertensive heart disease is high blood pressure, obesity and less exercise increases the risk. Obesity, less exercise
Although the main risk factor for hypertensive heart disease is high blood pressure, obesity and less exercise increases the risk.
Family history of hypertension Increases the risk of getting hypertensive heart disease. Family history of hypertension
Increases the risk of getting hypertensive heart disease.
History of smoking Increases the risk. History of smoking
Increases the risk.
History of dyslipidaemia. diabetes Hypertension, diabetic and dyslipidemia are major risk factors for cardiovascular disease
Hypertension is present in 20% to 60% of patients with type 2 diabetes, depending on age, ethnicity, obesity, and the presence of micro or macro albuminuria
History of dyslipidaemia. diabetes
Hypertension, diabetic and dyslipidemia are major risk factors for cardiovascular disease
Hypertension is present in 20% to 60% of patients with type 2 diabetes, depending on age, ethnicity, obesity, and the presence of micro or macro albuminuria
Male gender Men are more likely to get heart disease than women, at least until the age of menopause; men and postmenopausal women are equally at risk Male gender
Men are more likely to get heart disease than women, at least until the age of menopause; men and postmenopausal women are equally at risk
Old age Risk for heart disease increases with age Old age
Risk for heart disease increases with age

Clinicals - Examination

Fact Explanation
Irregular pulse Due to occurance of arrhythmia during silent myocardial ischemia Irregular pulse
Due to occurance of arrhythmia during silent myocardial ischemia
Dyspnea Atypical presentation of acute coronary disease Dyspnea
Atypical presentation of acute coronary disease
Fundoscopy examination Since diabetic patients are more prone to get SMI,changes of diabetic retinopathy may be present Fundoscopy examination
Since diabetic patients are more prone to get SMI,changes of diabetic retinopathy may be present
Loss of peripheral sensation Patients with neuropathies are more prone to get SMI ( eg: diabetic neuropathy ) Loss of peripheral sensation
Patients with neuropathies are more prone to get SMI ( eg: diabetic neuropathy )
Signs of diabetic dermopathy ( loss of body hair, pigmented patches,callous etc) Since diabetic patients are more prone to get SMI,changes of diabetic dermopathy may be present Signs of diabetic dermopathy ( loss of body hair, pigmented patches,callous etc)
Since diabetic patients are more prone to get SMI,changes of diabetic dermopathy may be present
Surgical scars Patients who had past surgeries for coronary artery disease, may have surgical scars Surgical scars
Patients who had past surgeries for coronary artery disease, may have surgical scars
High blood pressure Blood pressure levels may go up during a SMI High blood pressure
Blood pressure levels may go up during a SMI

Investigations - Diagnosis

Fact Explanation
Bed side electrocardiography (ECG) monitoring Continuous ECG monitoring is the mainstay of cardiac monitoring.The sensitivity and accuracy of detecting ST-T changes suggestive of ischemia (ST elevations and depressions) depend on the number of leads used during ECG monitoring Bed side electrocardiography (ECG) monitoring
Continuous ECG monitoring is the mainstay of cardiac monitoring.The sensitivity and accuracy of detecting ST-T changes suggestive of ischemia (ST elevations and depressions) depend on the number of leads used during ECG monitoring
Exercise stress testing Exercise stress testing combined with ECG testing has been used for the detection of ST-T changes secondary to myocardial ischemia and infarction Exercise stress testing
Exercise stress testing combined with ECG testing has been used for the detection of ST-T changes secondary to myocardial ischemia and infarction
Ambulatory ECG monitoring Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease
Accuracy of the Holter monitor is
greatly increased when the diagnosis of silent myocardial
ischemia is limited to the following conditions:
(1) at least 0.5 mm ST segment depression
(2) duration of ST segment depression >60 s
(3) reversibility of ST segment depression
Ambulatory ECG monitoring
Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease
Accuracy of the Holter monitor is
greatly increased when the diagnosis of silent myocardial
ischemia is limited to the following conditions:
(1) at least 0.5 mm ST segment depression
(2) duration of ST segment depression >60 s
(3) reversibility of ST segment depression
Radionuclide imaging techniques Ischemia may also be detected by radionuclide perfusion scanning Radionuclide imaging techniques
Ischemia may also be detected by radionuclide perfusion scanning
Intra cardiac monitoring includes an integrated, implantable lead and electronic processing box implanted in the subclavian area. The lead may be positioned in the right ventricular apex and can continuously measure more reliable physiological and hemodynamic parameters, as well as intra-cardiac electrograms relevant to the detection of myocardial ischemia Intra cardiac monitoring
includes an integrated, implantable lead and electronic processing box implanted in the subclavian area. The lead may be positioned in the right ventricular apex and can continuously measure more reliable physiological and hemodynamic parameters, as well as intra-cardiac electrograms relevant to the detection of myocardial ischemia
Near-infrared spectroscopy Intravascular near-infrared spectroscopy is an emerging tool for the detection of myocardial ischemia. The intravascular near-infrared spectral analysis of the coronary sinus blood with a fibre optic catheter can be a reliable diagnostic tool for the on-line detection and follow-up of acute myocardial ischemia Near-infrared spectroscopy
Intravascular near-infrared spectroscopy is an emerging tool for the detection of myocardial ischemia. The intravascular near-infrared spectral analysis of the coronary sinus blood with a fibre optic catheter can be a reliable diagnostic tool for the on-line detection and follow-up of acute myocardial ischemia
Computed tomography (CT) Recently, multislice computed tomography (CT) has been shown to be capable of visualizing not only the coronary arteries (wall and lumen), but also the cardiac muscle, with high spatial resolution.Noninvasive visualization of the coronary arteries and accurate detection of stenosis are now possible with ECG-gated 16-slice CT Computed tomography (CT)
Recently, multislice computed tomography (CT) has been shown to be capable of visualizing not only the coronary arteries (wall and lumen), but also the cardiac muscle, with high spatial resolution.Noninvasive visualization of the coronary arteries and accurate detection of stenosis are now possible with ECG-gated 16-slice CT
Coronary angiography Detection of the blocks, narrowing in the coronary vessels Coronary angiography
Detection of the blocks, narrowing in the coronary vessels

Investigations - Management

Fact Explanation
Ambulatory ECG monitoring Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease Ambulatory ECG monitoring
Helps to stratify the risk of serious events (intense activity,psychological stresses etc.) in patients with various forms of heart disease
Lipid profile Low density lipoprotein levels are expected to be kept <100mg/dl in patients with coronary artery disease as dyslipidemia increases the risk of silent myocardial infarction Lipid profile
Low density lipoprotein levels are expected to be kept <100mg/dl in patients with coronary artery disease as dyslipidemia increases the risk of silent myocardial infarction
Fasting blood sugar Patients with diabetes and silent myocardial infarction (SMI) have a very poor prognosis, as reflected by adverse cardiac events or death.Therefore tight glycemic control is expected. Normal FBS-<126mg/dl Fasting blood sugar
Patients with diabetes and silent myocardial infarction (SMI) have a very poor prognosis, as reflected by adverse cardiac events or death.Therefore tight glycemic control is expected. Normal FBS-<126mg/dl
Echocardiogram To check for left ventricular function by assessing ejection fraction as the patients with coronary heart disease may go into heart failure Echocardiogram
To check for left ventricular function by assessing ejection fraction as the patients with coronary heart disease may go into heart failure
Hemoglobin A1C levels Silent ischemia is also associated with higher hemoglobin A1C levels, reflecting the importance of achieving and maintaining euglycemia Hemoglobin A1C levels
Silent ischemia is also associated with higher hemoglobin A1C levels, reflecting the importance of achieving and maintaining euglycemia
Lipid profile Assess other co morbid conditions. Dyslipidemia increases the risk of getting silent myocardial ischemia (SMI) Lipid profile
Assess other co morbid conditions. Dyslipidemia increases the risk of getting silent myocardial ischemia (SMI)
Full blood count To check for hemoglobin levels as anemia may further worsen the cardiac function Full blood count
To check for hemoglobin levels as anemia may further worsen the cardiac function
Fasting blood sugar To assess other co morbid conditions.Diabetes is a major risk factor which gives rise to silent myocardial infarction Fasting blood sugar
To assess other co morbid conditions.Diabetes is a major risk factor which gives rise to silent myocardial infarction
Bed side electrocardiography (ECG) monitoring Continuous ECG monitoring is the mainstay of cardiac monitoring.The sensitivity and accuracy of detecting ST-T changes suggestive of ischemia (ST elevations and depressions) depend on the number of leads used during ECG monitoring Bed side electrocardiography (ECG) monitoring
Continuous ECG monitoring is the mainstay of cardiac monitoring.The sensitivity and accuracy of detecting ST-T changes suggestive of ischemia (ST elevations and depressions) depend on the number of leads used during ECG monitoring
Fasting blood sugar To diagnose udetected diabetes (FBS >126mg/dl with symptoms of diabetes).
Diabetic patients are more prone to get silent myocardial infarctions
Fasting blood sugar
To diagnose udetected diabetes (FBS >126mg/dl with symptoms of diabetes).
Diabetic patients are more prone to get silent myocardial infarctions
Lipid profile To screen for dyslipidemia. Dyslipidemia increases the risk of getting SMI.
Low density lipoprotein levels are expected to be kept <100mg/dl in patients with coronary artery disease
Lipid profile
To screen for dyslipidemia. Dyslipidemia increases the risk of getting SMI.
Low density lipoprotein levels are expected to be kept <100mg/dl in patients with coronary artery disease

Management - Supportive

Fact Explanation
Dietary modifications Diet low in cholesterol,sugar and low in alcohol consumption Dietary modifications
Diet low in cholesterol,sugar and low in alcohol consumption
Exercise Regular exercise, such as walking, running, cycling, or swimming has been shown to improve cardiovascular well-being Exercise
Regular exercise, such as walking, running, cycling, or swimming has been shown to improve cardiovascular well-being
Control of other factors which may increase the risk Hypercholesterolemia, high blood sugar,cigarette smoking are potentially modifiable risk factors Control of other factors which may increase the risk
Hypercholesterolemia, high blood sugar,cigarette smoking are potentially modifiable risk factors
Patient education Educate regarding the risk factors, controlling of other co morbid conditions,avoiding the events which may lead to myocardial ischemia Patient education
Educate regarding the risk factors, controlling of other co morbid conditions,avoiding the events which may lead to myocardial ischemia

Management - Specific

Fact Explanation
Beta blockers Beta blockers reduce the incidence, frequency, duration, and severity of silent ischemia in a dose-dependent manner. Furthermore,have been shown to blunt the circadian pattern of transient ischemia, particularly the morning peak of ischemic activity, which closely mirrors the circadian incidence of acute myocardial infarction and sudden death. Beta blockers
Beta blockers reduce the incidence, frequency, duration, and severity of silent ischemia in a dose-dependent manner. Furthermore,have been shown to blunt the circadian pattern of transient ischemia, particularly the morning peak of ischemic activity, which closely mirrors the circadian incidence of acute myocardial infarction and sudden death.
Calcium antagonists Act as vasodilators and relieve the ischemia Calcium antagonists
Act as vasodilators and relieve the ischemia
Surgical treatment Revascularization, particularly surgery, was superior to pharmacological therapy in improving prognosis.
Primary coronary intervention, coronary by pass grafting is generally more effective in reducing silent ischemic episodes
Surgical treatment
Revascularization, particularly surgery, was superior to pharmacological therapy in improving prognosis.
Primary coronary intervention, coronary by pass grafting is generally more effective in reducing silent ischemic episodes

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