Types of Coronary Artery Heart Disease and Diagnosis

Types of Coronary Artery Heart Disease and Diagnosis .

Diagnosis of coronary artery disease

Angina

• Resting ECG: ECG may show previous myocardial infarction but is normal in most of the patients. During anginal episode, ECG may show ST depression or elevation. This may disappear with rest or sublingual Nitrates or Nifedipine.
• Stress test: A formal exercise tolerance test is usually performed using a standard treadmill or bicycle ergometer. The workload is gradually increased by increasing the speed and elevation of the treadmill while monitoring the ECG, blood pressure & general condition of the patient .The test should be stopped if the patient gets dyspnoea , hypotension or chest pain.
  
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  Down slopping ST depression is more indicative of ischemia. ST depression can occur in a normal patient. This test is very popular but can give false positive or false negative result.
• Thallium Test: The test is done by injecting thallium while the patient exercises and the regional myocardial perfusion are assessed by a gamma camera. Thallium is picked up only by normal myocardium; ischemic area would appear as perfusion. The necrosed area remains cold. This has 85% of specificity & sensitivity.
• Holter monitoring: Ambulatory ECG monitor may detect episodes of ST segment changes during normal activities.
  
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  Some of the episodes of ST-T changes may not be accompanied by symptoms.
• Coronary Arteriography: This provides detailed information about the extent and nature of coronary artery disease. It is usually performed a view to coronary bypass grafting or angioplasty.

Myocardial infarction

• ECG: The earliest change ST segment elevation with onset of pain. Q wave appear when trans mural infarction occurs. By about 24 hours ST segment reverts to normal and T wave becomes inverted. In the leads opposite to the site of infarction there is ST depression even earlier than the ST elevation. Depending upon the area involved these changes are seen in respective leads:-/> Anterior wall:  V1-V4/> Lateral wall: I, V6 and aVL./> Anteroseptal: V1, V3 and V4/> Medial wall: V1 and V2/> Inferior: II, III and aVF
• Serum enzymes:  Myocardial necrosis leads to liberation of certain enzymes which may be elevated in blood. SGOT, LDH, CPK levels rise.
• Echocardiography: It detects myocardial ischemia, right & left ventricular function and also the important complication such that cardiac rupture, mitral regurgitation and pericardial effusion.
• Radionuclide scanning: A radionuclide ventriculogram can be used to assess left ventricular function and may provide useful prognostic information.
• Angiography: Done when primary PTCA (Percutaneous transluminal coronary angioplasty) is to be done.

 Arrhythmia

• Ventricular Fibrillation: It produces rapid ineffective uncoordinated movements of the ventricles. ECG shows chaotic, bizarre, irregular complexes.
• Ventricular Tachycardia (VT): VT is continuous run with the QRS complexes smoothly merging with the ST segment and T waves giving an appearance large, wide undulation which are irregular. QRS complexes rate of between 140-220/minute.
• Ventricular Ectopic beats: ECG shows premature broad bizarre QRS complexes which may be unifocal or multifocal.
• Atrial Fibrillation: ECG shows normal but irregular QRS complexes, there are no P waves but the baseline may show irregular fibrillation waves.
• Atrial Flutter: Fast atrial rate of 300/ minutes with ventricular rate half or one fourth of the atrial rate. P waves are replaced by flutter wave ventricular rhythm usually regular, unless there is a changing AV block.
• Atrial Tachycardia: ECG shows atrial rate more than 150/ minute, abnormal P waves often accompanied by atrio-ventricular block.
• Supraventricular tachycardia: ECG shows tachycardia with normal QRS complexes & the rate is 180 / min. Occasionally there may be rate dependent bundle branch block.