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  1. 1. CAD & ACS
  2. 2. CORONARY ARTERY DISEASE <ul><li>Coronary artery disease is a chronic disease caused </li></ul><ul><li>by the gradual deposition of fats in the coronary </li></ul><ul><li>arteries (atherosclerosis). </li></ul><ul><li>Narrowed artery reduces oxygen supply to the </li></ul><ul><li>myocardium. </li></ul><ul><li>Ischemia ( reduced blood & O 2 supply ) often causes </li></ul><ul><li>chest pain or discomfort known as angina pectoris or </li></ul><ul><li>Myocardial Infarction due to complete blockage. </li></ul><ul><li>CAD is also called as IHD & CHD. </li></ul>
  3. 3. CAD <ul><li>Atherosclerosis : </li></ul><ul><li>Deposition of lipids under the intima of arteries. Chronic process that develops in following stages over 30-40 years </li></ul><ul><li>Fatty streak </li></ul><ul><li>Fibrous plaque </li></ul><ul><li>Rupture </li></ul>
  4. 6. ATHEROSCLEROSIS: HARMFUL CONSEQUENCES Atherosclerosis causes decrease in lumen of arteries and thus decreases blood supply Artery involved Organ Condition Symptoms Events Coronary Heart CAD Angina MI Cerebral carotid Brain CVD TIA Stroke Peripheral Peripheral tissue (sk muscle) PVD/PAD Intermittent claudication Gangrene
  5. 7. SYMPTOMS OF CAD <ul><li>Chest pain (angina) : Patient may feel pressure or tightness in chest, as if someone is standing on chest. </li></ul><ul><li>Shortness of breath. </li></ul>
  6. 8. ANGINA PECTORIS <ul><li>Principle symptom of CAD (IHD, CHD) </li></ul><ul><li>Sudden, severe & temporary chest pain caused by an inadequate supply of oxygen to the myocardium due to narrowing of the coronary artery </li></ul><ul><li>Pain may radiate to left arm or shoulder, back, neck or jaw </li></ul><ul><li>The symptoms usually last for few minutes and pain subsides on rest. </li></ul><ul><li>No permanent damage occurs </li></ul><ul><li>Angina may be is precipitated by exercise, cold, stress, heavy meal </li></ul>
  7. 9. TYPES OF ANGINA <ul><li>Variant / Vasospastic </li></ul><ul><li>Caused by spasm of the coronary arteries </li></ul><ul><li>May occur at rest, may not be precipitated by emotion or stress. </li></ul>Chronic Stable angina (CSA) Unstable angina (UA) Other names Exertional / classical Preinfarct Angina Occurrence Usually precipitated by physical activity Occurs even at rest Predictability Predictable Unpredictable Frequency, severity & duration of pain Less More Cause Stable plaque (atherosclerosis) Unstable plaque (atherothrombosis) Relieving factors Rest or sublingual nitrates Requires hospitalization
  8. 10. MYOCARDIAL INFARCTION Myocardium : heart muscle Infarction : death of the tissue (necrosis) MI is death of the myocardial tissue due to complete blockade of coronary artery
  9. 11. ISCHEMIA & MYOCARDIAL INFARCTION Ischemia Myocardial infarction Partial block of artery Complete block of artery Temporary decrease in O 2 supply Permanent damage (necrosis) ST Segment depression Usually ST Segment elevation
  10. 12. ANGINA PECTORIS <ul><li>Determinants of the myocardial O 2 </li></ul><ul><li>requirement : </li></ul><ul><ul><li>Heart rate </li></ul></ul><ul><ul><li>Myocardial contractility </li></ul></ul><ul><ul><li>Afterload </li></ul></ul><ul><ul><li>Preload </li></ul></ul>
  11. 13. ACUTE CORONARY SYNDROME <ul><li>It is an umbrella term used to describe symptoms and signs occuring because of acute atherothrombosis in coronary artery </li></ul><ul><li>It is an emergency condition and patient has to be hospitalized </li></ul>
  12. 14. CLASSIFICATION OF ACS <ul><li>ACS includes 3 syndromes: UA, NSTEMI, STEMI </li></ul><ul><li>They are different manifestations of the same clinical </li></ul><ul><li>syndrome depending upon the period of severity </li></ul>* Troponin T & CKMB Unstable angina NSTEMI STEMI Typical chest pain Yes Yes Yes Elevation of serum cardiac enzymes* No Yes Yes ST Segment elevation No No Yes
  13. 15. Investigations in ACS & CAD
  14. 16. ECG <ul><li>Recording of electrical activity of the heart via electrodes attached to the skin </li></ul><ul><li>Net sum of depolarisation and repolarisation potentials of all myocardial cells </li></ul><ul><li>P-QRS-T pattern </li></ul><ul><li>P - atrial depolarisation </li></ul><ul><li>QRS - ventricular depolarisation </li></ul><ul><li>T - ventricular repolarisation </li></ul>
  15. 17. ECG ABNORMALITIES IN ISCHEMIA & MI ECG (Electrocardiogram)
  16. 18. <ul><li>Stress test (Treadmill Test/TMT/CST) </li></ul><ul><li>Patients are asked to walk on a treadmill during </li></ul><ul><li>an ECG. </li></ul><ul><li>This is the test to unmask CAD when resting ECG </li></ul><ul><li>is normal </li></ul>INVESTIGATION OF CAD
  17. 19. <ul><li>A diagnostic procedure </li></ul><ul><li>Cardiac catheterization done </li></ul><ul><li>‘ Catheter’ refers to a long narrow rubber tube inserted through artery of leg & advanced upto the opening of coronary artery in aorta </li></ul><ul><li>A small amount of contrast material (dye) is injected through the catheter into coronary arteries </li></ul>INVESTIGATION OF CAD Coronary angiography
  18. 20. <ul><li>The movement of the dye is recorded as an angiogram and viewed on a television monitor. </li></ul><ul><li>Images are then captured using X-rays. </li></ul><ul><li>Disease is described in terms of </li></ul><ul><ul><li>Extent & location of block : e.g. 90% block in proximal RCA </li></ul></ul><ul><ul><li>Number of arteries involved: Single-vessel, double-vessel or triple-vessel disease </li></ul></ul>INVESTIGATION OF CAD Coronary angiography
  19. 21. TREATMENT OF ANGINA (CAD) <ul><li>Life style modification </li></ul><ul><ul><li>Regular physical exercise </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul><ul><ul><li>Stop alcohol </li></ul></ul><ul><ul><li>Dietary controls : weight control </li></ul></ul><ul><ul><ul><li>Restrict saturated fats </li></ul></ul></ul><ul><li>Pharmacological </li></ul><ul><ul><li>Organic nitrates : Nitroglycerine, ISMN </li></ul></ul><ul><ul><li>CCBs : Diltiazem, Verapamil </li></ul></ul><ul><ul><li>Beta Blockers : Metoprolol, nebivolol </li></ul></ul><ul><ul><li>K + Channel opener : Nicorandil </li></ul></ul><ul><li>Interventional </li></ul><ul><ul><li>PTCA </li></ul></ul><ul><ul><li>CABG </li></ul></ul>
  20. 22. ORGANIC NITRATES <ul><li>Dilates veins & large arteries </li></ul><ul><li>Dilation of veins lead to reduction of the preload </li></ul><ul><li>Dilation of the arteries leads to reduction of the afterload </li></ul><ul><li>Coronary artery dilation </li></ul>
  21. 23. BETA BLOCKERS <ul><ul><li>Reduces Myocardial Oxygen Demand </li></ul></ul><ul><ul><li>↓ Heart Rate </li></ul></ul><ul><ul><li>↓ Force of contraction </li></ul></ul><ul><ul><li>Increases Coronary filling </li></ul></ul><ul><ul><li>↑ Diastolic time </li></ul></ul>
  22. 24. CCBs Block Calcium channels Prevent entry of Ca++ ions Myocardial Cell Vascular smooth muscle Decreased force of Coronary Artery Peripheral contraction arteriole Coronary blood flow PVR
  23. 25. NICORANDIL Nitrate-like action K + channel opener ATP Dilates epicardial Coronary arteries Venodilatation Dilates peripheral arterioles Dilates coronary Resistance vessels Decreased Preload Decreased afterload ↑ coronary blood flow ↓ Myocardial O 2 requirement ↓ Myocardial O 2 requirement ↑ coronary blood flow Nicorandil dual action
  24. 26. PTCA WITH STENTING (Percutaneous Transluminal Coronary Angioplasty) <ul><li>Also known as </li></ul><ul><ul><li>Balloon angioplasty </li></ul></ul><ul><ul><li>Angioplasty </li></ul></ul><ul><ul><li>PCI (percutaneous coronary intervention) </li></ul></ul><ul><li>Done in Cardiac Catheterization Laboratory (Cath Lab) by an interventional cardiologist </li></ul>
  25. 27. PTCA WITH STENTING Opening of the artery after stenting The arrow on the angiogram shows block in the artery.
  26. 28. CABG (Coronary Artery Bypass Graft Surgery) (Done by CVTS in Cardiac OT)
  27. 29. Thank You