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Ischemic Heart Disease
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- 2. Coronary artery disease •Risk factors for coronary artery disease • Pathogenesis • Clinical presentation • Treatment overview
- 3. Risk factors forcoronary artery disease
- 4. Risk Factors forCoronary artery disease Non-modifiable Age Family history Sex Modifiable Cigarette smoking Diabetes mellitus Hyperlipidemia Hypertension
- 5. Other less importantrisk factors • Obesity • Physical inactivity • Stress ( type A personality) • Postmenopausal estrogen deficiency • Alcohol
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- 7. Atherosclerosis The underlying pathogenesisof coronary arterial disease is atherosclerosis
- 8. Atherosclerosis Atherosclerosis = “Hardeningof the vessels”
- 9. Smoking Blood pressure Cholesterol Diabetes mellitus Other factors Atherosclerosis Thrombosis Heartattack Brain attack Other vascular Development of atherosclerosis
- 10. Atherosclerosis • The keyprocesses in atherosclerosis are – intimal thickening – lipid accumulation • These processes will produced the atheromatous plaque
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- 12. Atheroma in coronaryartery
- 13. Atheromatous plaque/ Atheroma Fattystreak Atheroma
- 14. Response to InjuryHypothesis • Atherosclerosis is a chronic inflammatory response of the arterial wall initiated by some form of injury to the endothelium
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- 16. Chronic repetitive injury SmokingHypertension Hyperlipidemia Endothelial injury
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- 23. Coronary artery atherosclerosis •Most of the patients with coronary artery disease has coronary atherosclerosis which cause obstruction to blood flow
- 24. Effect of atherosclerosis •Most have one or more lesions causing at least 75% reduction of the cross-sectional area of coronary arteries • Coronary Artery Disease = insufficient flow of blood through coronary arteries
- 27. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
- 28. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
- 29. Asymptomatic • The degreeof obstruction sometimes do not correlate with symptoms. • Patient may be still asymptomatic despite high degree of obstruction • Patient may also loss the sensation of pain as a result of neuropathy especially with diabetes mellitus
- 30. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
- 31. Sudden death • Maybe the first manifestation in 25% of patients • 20% of patients with AMI will died before reaching hospital • Most of these death are caused by ventricular fibrillation
- 32. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
- 33. Angina Pectoris • Imbalanceof oxygen supply and demand • Decreased blood flow to myocardium • Results in chest pain – Switch to anerobic metabolism – Lactic acid build up – Kinins, histamine, other substances released – Nerve fibers are stimulated
- 35. Angina Pectoris • paroxysmaland usually recurrent attacks of substernal or precordial chest discomfort • described as constricting, squeezing, choking, or knifelike
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- 38. Typical Angina • Retrosternalchest pain – Dull – Pressing • Aggravated by exertion • Relieved by GTN or by rest • Associated with nausea, vomiting and sweating
- 39. Canadian Cardiovascular Society(CCS) ANGINA Functional Class Symptoms I Normal ordinary activity Angina with strenuous exercise II Slight limitation of ordinary activity III Marked limitation of ordinary activity IV Inability to perform any activity without symptom. May be present at rest
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- 42. Types of angina Angina Stableangina Prinzmetal variant angina Unstable angina
- 43. Stable angina • Alsocalled exertional angina • The lumen of coronary artery is narrowed and hard; thus, dilation in response to increased demand is impossible
- 44. Stable angina • Initiatedby known amount of activity • Same activity tends to produce same symptoms • Produced by – physical activity – emotional excitement – cause of increased cardiac workload • Relieved by rest, Nitrate
- 45. Printzmetal angina • Alsocalled variant angina, Prinzmetal’s variant angina • An uncommon pattern of episodic angina that occurs at rest • Due to coronary artery spasm.
- 46. Printzmetal angina • Occurswithout a precipitating event, usually at the same time of day • Often awakens patient from sleep • Unpredictable, occurs most often at rest
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- 48. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
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- 52. ATHEROMATOUS PLAQUE PLAQUERUPTURE PLAQUE RUPTURE
- 53. Clinical features ofAcute Myocardial Infarction • Angina – Prolonged – Not relieved by usual dose of nitrates • Sweating • Nausea and vomiting • Palpitation • Dyspnea • Sudden death
- 54. Acute coronary syndrome •Angina occurs at rest or on minimum exertion • Not relieved by usual doses of GTN • The pain last longer (> 20 minutes) • Increasing in duration/severity/frequency
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- 59. Cardiac enzymes • Myoglobulin •Troponin • Creatinine kinase (MB) • ALT • Lactate dehydrogenase
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- 61. Cardiac Enzymes inACS Test Onset Peak Duration Myoglobulin 1-4 hours 6-7 hours 24 hours Troponin 3-12 hours 18-24 hours Up to 10 days CK-MB 3-12 hours 18-24 hours 36-48 hours LDH 6-12 hours 24-48 hours 6-8 days
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- 63. Non ST elevationMI • Typical chest pain • Raised cardiac enzymes • NO ST elevation in ECG – But may have other ECG changes
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- 66. Unstable angina • Chestpain • NO cardiac enzyme changes • NO ST elevation in ECG
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- 68. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
- 69. Heart failure • Inrecurrent myocardium ischemia, the myocardium will loss function • This will progress to reduced left ventricular function and cause heart failure
- 70. Signs and symptoms •Orthopnea • Reduced effort tolerance • Paroxysmal nocturnal dyspnea • Raised JVP • Acute pulmonary edema
- 71. Orthopnea • Unable tolie flat • Sometimes need to sit up to sleep • Severity judged by number of pillows required to sleep on
- 72. Paroxysmal Nocturnal Dyspnea •waking up in about 2-3 am • breathlessness Lying Down
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- 74. ECHO: Poor LVEF •Dilated LV • Dilated LA • Globally poor LV contraction
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- 76. End of PhaseII 11.8.09 Lifestyle modifications Smoking Diabetes Male Hypertension Obesity Lack of exercise Stress
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- 79. Antiplatelet • Aspirin • ADPreceptor antagonist – Ticlopidine – Clopidogrel
- 80. Antiplatelet • Chronic angina –Aspirin for life – ADP receptor antagonist if aspirin intolerable • Acute coronary syndrome – Dual antiplatelet
- 81. Thrombolytic • Lyse theclot that block the blood flow • Examples – Streptokinase – rTPA • Only in acute myocardial infarct
- 82. Anticoagulant - Heparin •Heparin • Low molecular weight heparin • oligosaccharides (fondaparinux) • Heparinoid
- 83. Anticoagulant - Heparin •Used in acute coronary syndrome • Currently favors oligosaccharides (fondaparinux) – Less bleeding complications – Single daily injection – Halal
- 84. COX (cyclo-oxygenase) ADP (adenosinediphosphate) TXA2 (thromboxane A2) Thienopyridines ASA COX ADP ADP C GPllb/llla (Fibrinogen receptor) Collagen thrombin TXA2 Activation TXA2 ASA Synergistic Mode of Action with Clopidogrel and ASA1 1. Schafer AI. Am J Med 1996; 101: 199–209.
- 85. Glycoprotein IIb/IIIa inhibitors •Examples – Abciximab – Tirofiban – Eptifibatide • Used mainly in – Unstable angina – NSTEMI
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- 89. PCI of coronaryartery •The narrowing was openned with a angioplasty balloon • A stent was inflated after the balloon angioplasty
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- 91. Coronary artery disease •ACE inhibitor/Angiotensin receptor blocker • Beta Blocker • Calcium channel blocker if not tolerable to beta blocker
- 92. Treat the concomitantconditions • Hypertension • Diabetes Mellitus • Hyperlipidemia
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- 94. Smoking Blood pressure Cholesterol Diabetes mellitus Other factors Atherosclerosis Thrombosis Heartattack Brain attack Other vascular Development of atherosclerosis
- 96. Presentation of coronaryheart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure
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