Artery disorders

1. Coronary Heart Disease
Dr. Tilak Abeysekara
tilak_1@Hotmail.com

2. Coronary arteries anatomy

4. Atherosclerosis
• Begin early in life clinical manifestation appear after sixty years
• Progressive inflammatory disorder of the arterial wall characterized
by focal lipid-rich deposits
• Remain clinically silent until they become large enough to impair
tissue per-fusion or until ulceration and disruption of the lesion
results in thrombotic occlusion or distal embolization

5. Stages of Atherosclerosis

6. Risk factors
• Age and sets
• Family history
• Smoking
• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Hemostatic factors
• Physical activities
• Obesity
• Alcohol
• Other dietary factors
• Personality
• Social deprivation

7. Primary Prevention
• No smoking
• Regular exercises
• Ideal body weight
• Dietary advice

8. Secondary prevention
• All of primary prevention
• Statins
• Aspirin
• ACE inhibitors
• Beta blockers

9. Coronary Heart Disease
• Stable angina
• Acute coronary syndrome
 Unstable angina
 Myocardial infarction
NSTEMI
STEMI

10. Stable angina
• Chest pain / breathlessness on exertion

11. Activity precipitating angina
• Physical exertion
• Cold exposure
• Heavy meals
• Intense emotion
• Vivid dreams

12. Features of angina
• Central diffuse
• Radiation
• Precipitated by exertion
• Rest relive pain

13. Investigations
• Resting ECG
• Exercise ECG
• Coronary arteriography

14. Management
• General Measures
 Do not smoke
 Ideal body weight
 Regular exercise

15. Antiplatelet therapy
• Aspirin
• Clopidogrel

16. Anti- anginal treatment
• Nitrates
 Sublingual
 Transdermal
 Oral
• Beta Blockers
• Calcium channel blockers
• Nicorandil
• Ivabradine

17. Invasive treatment
• Percutaneous coronary intervention (PCI)
• Coronary artery bypass grafting (CABG)

18. Acute coronary syndrome
• Unstable angina – No Myocardial damage
• Myocardial infarction - ST elevated MI
- Non ST elevated MI

19. Clinical features
• Symptoms
• Physical signs

20. Investigations
• ECG
• Plasma cardiac markers – Troponin I
• Chest X-Ray
• Echocardiography

21. Immediate management
• Admit
• Analgesia – Morphine IV
• Antithrombotic therapy
 Antiplatelet therapy
 Anticoagulants – Heparin
• Anti - angina therapy

22. Immediate management
• Reperfusion therapy
 Non-ST elevated MI / No benefit
 ST elevated MI – Primary percutaneous coronary intervention
(PCI) / Thrombolysis (human tissue plasminogen activator)

23. Complications
• Arrhythmias
• Acute circulatory failure
• Pericarditis
• Mechanical complications
• Embolism
• Impaired ventricular function

24. Late management
• Lifestyle modification
• Mobilization and rehabilitation
• Secondary prevention drug therapy (Antiplatelet, Beta blockers, ACE
inhibitors)

25. Angina in old age
• Incidence
• Comorbid conditions
• Calcific aortic stenosis
• Atypical presentations
• Angioplasty and coronary artery bypass surgery