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Ischemic Heart Disease: Diagnosis
Medical expert of the article
Last reviewed: 23.04.2024
A reliable diagnosis of IHD based on questioning, history and physical examination is possible only in patients with classical angina or with documented myocardial infarction with a Q-wave in the anamnesis (postinfarction cardiosclerosis). In all other cases, for example, with atypical pain syndrome, the diagnosis of IHD is less reliable and has a presumptive character. The confirmation of the results of additional instrumental research methods is necessary.
By the nature of pain in the chest, the probability of having an ischemic heart disease can be assessed.
- "Classical" angina of stress - the probability of IHD is 80-95%.
- Atypical pain syndrome (there are not all signs of typical angina pectoris, for example, there is no clear connection with exercise) - the probability of coronary artery disease is about 50%.
- Obviously non-anginal pain (cardialgia), there is not a single sign of angina pectoris - the probability of IHD is 15-20%.
These figures are calculated for men. In women, the probability of IHD is much lower. For example, in men older than 30 years, with typical angina, the probability of IHD is about 90%, and in women 40-50 years-only 50-60% (no more than in men with atypical pain syndrome).
Typical angina of stress in patients without IHD (without coronary artery disease) can be observed in patients with aortic stenosis, hypertrophic cardiomyopathy, arterial hypertension (with left ventricular hypertrophy), heart failure. In these cases "ischemia and angina without IHD" takes place.
Instrumental methods of diagnosis of ischemic heart disease
ECG registration at rest.
ECG registration during an attack of angina pectoris.
Long-term monitoring of the ECG.
Samples with loading:
- exercise stress,
- electrostimulation of the atria. Pharmacological tests:
- with dipyridamole (curantyl),
- with isoproterenol (isadrin),
- with dobutamine,
- with adenosine.
Radionuclide methods for diagnosis of ischemic heart disease
Echocardiography.
Coronary angiography.
The signs of ischemia during functional tests are revealed with the help of ECG, echocardiography and radionuclide methods.
ECG registration during an attack of angina
In the provision of emergency care, the main importance is the registration of the ECG during an attack of angina pectoris. If there are no changes in the ECG during an attack, this does not exclude the presence of myocardial ischemia, but the probability of ischemia is low in these cases (even if the cause of the pain is ischemia, the prognosis in such patients is more favorable than in patients with ECG changes during seizures). The appearance of any ECG changes during an attack or after it increases the likelihood of myocardial ischemia. The most specific changes in the ST segment.
Depression of the ST segment is a reflection of subendocardial myocardial ischemia, elevation of the ST segment is a sign of transmural ischemia (most often due to spasm or thrombosis of the coronary artery). Recall that signs of ischemia can be noted in patients who do not have IHD, for example, with left ventricular hypertrophy. When recording persistent ST segment elevation, "acute coronary syndrome with ST-segment elevation" is diagnosed, and with a prolonged attack of angina with any changes on the ECG (except for ST rise) or even without ECG changes, "acute coronary syndrome without ST segment elevation" is diagnosed.
[12], [13], [14], [15], [16], [17], [18], [19]
The formulation of the diagnosis of coronary heart disease
After the abbreviation of IHD, it is necessary to indicate the specific manifestations of myocardial ischemia: angina pectoris, myocardial infarction, postinfarction cardiosclerosis, acute coronary syndrome, or painless myocardial ischemia. After that, indicate complications of IHD, for example, heart rhythm disorders or heart failure. It is inadmissible to use the term "atherosclerotic cardiosclerosis" instead of manifestations of myocardial ischemia. There are no clinical criteria for this term. It is also impossible immediately after the abbreviation of IHD to indicate cardiac arrhythmias, as the only manifestation of IHD. In this case, it is unclear on what basis the ischemic heart disease is diagnosed, if there are no signs of myocardial ischemia.