cvs

1. Ischemic Heart
Disease

2. Coronary artery disease
• Risk factors for coronary artery disease
• Pathogenesis
• Clinical presentation
• Treatment overview

3. Risk factors for coronary
artery disease

4. Risk Factors for Coronary artery
disease
Non-modifiable
 Age
 Family history
 Sex
Modifiable
 Cigarette smoking
 Diabetes mellitus
 Hyperlipidemia
 Hypertension

5. Other less important risk factors
• Obesity
• Physical inactivity
• Stress ( type A personality)
• Postmenopausal estrogen deficiency
• Alcohol

6. Pathogenesis of coronary
artery disease

7. Atherosclerosis
The underlying pathogenesis of
coronary arterial disease is
atherosclerosis

8. Atherosclerosis
Atherosclerosis = “Hardening of the vessels”

9. Smoking
Blood
pressure
Cholesterol
Diabetes
mellitus
Other
factors
Atherosclerosis Thrombosis Heart attack
Brain attack
Other
vascular
Development of atherosclerosis

10. Atherosclerosis
• The key processes in atherosclerosis are
– intimal thickening
– lipid accumulation
• These processes will produced the atheromatous plaque

11. Atheromatous plaque

12. Atheroma in coronary artery

13. Atheromatous plaque/ Atheroma
Fatty streak
Atheroma

14. Response to Injury Hypothesis
• Atherosclerosis is a chronic inflammatory response of
the arterial wall initiated by some form of injury to the
endothelium

15. Smooth endothelium

16. Chronic repetitive injury
Smoking Hypertension Hyperlipidemia
Endothelial
injury

17. Response to injury

22. Pathogenesis of myocardial
ischemia

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 coronary heart
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 coronary heart
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 degree of 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 coronary heart
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
• May be 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 coronary heart
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
• Imbalance of 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
• paroxysmal and usually recurrent attacks of substernal
or precordial chest discomfort
• described as constricting, squeezing, choking, or
knifelike

36. Typical Angina

37. Typical Angina

38. Typical Angina
• Retrosternal chest 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

40. Typical Angina

42. Types of angina
Angina
Stable angina
Prinzmetal variant
angina
Unstable angina

43. Stable angina
• Also called exertional angina
• The lumen of coronary artery is narrowed and hard; thus,
dilation in response to increased demand is impossible

44. Stable angina
• Initiated by 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
• Also called variant angina, Prinzmetal’s variant angina
• An uncommon pattern of episodic angina that occurs at
rest
• Due to coronary artery spasm.

46. Printzmetal angina
• Occurs without a precipitating event, usually at the same
time of day
• Often awakens patient from sleep
• Unpredictable, occurs most often at rest

47. Coronary Angioplasty
Before After

48. Presentation of coronary heart
disease
Asymptomatic Chronic stable
angina
Acute coronary
syndrome (ACS) Death
(MI = Myocardial Infarction)
Unstable angina
Non ST elevation MI
ST elevation MI
Heart failure

49. Acute coronary syndrome
Acute
Coronary
Syndrome
Unstable
angina
Non-ST
Elevation
Myocardial
Infarct
Acute
Myocardial
infarct

50. ATHEROMATOUS PLAQUE
PLAQUE RUPTURE

51. ATHEROMATOUS PLAQUE
PLAQUE RUPTURE

52. ATHEROMATOUS PLAQUE PLAQUE RUPTURE
PLAQUE RUPTURE

53. Clinical features of Acute 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

55. Acute Coronary Syndrome

56. ECG changes of AMI

57. Anterior myocardial infarct

58. Inferior myocardial infarct

59. Cardiac enzymes
• Myoglobulin
• Troponin
• Creatinine kinase (MB)
• ALT
• Lactate dehydrogenase

60. Cardiac Enzymes in ACS

61. Cardiac Enzymes in ACS
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

62. Acute Coronary Syndrome

63. Non ST elevation MI
• Typical chest pain
• Raised cardiac enzymes
• NO ST elevation in ECG
– But may have other ECG changes

64. NSTEMI: ECG changes

65. Acute Coronary Syndrome

66. Unstable angina
• Chest pain
• NO cardiac enzyme changes
• NO ST elevation in ECG

67. Acute coronary syndrome
Acute
Coronary
Syndrome
Unstable
angina
Non-ST
Elevation
Myocardial
Infarct
Acute
Myocardial
infarct

68. Presentation of coronary heart
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
• In recurrent 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 to lie 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

73. Acute pulmonary edema

74. ECHO: Poor LVEF
• Dilated LV
• Dilated LA
• Globally poor LV contraction

75. Treatment

76. End of Phase II 11.8.09
Lifestyle modifications
Smoking
Diabetes
Male
Hypertension
Obesity
Lack of exercise
Stress

77. Lifestyle modifications

78. Lifestyle modifications

79. Antiplatelet
• Aspirin
• ADP receptor antagonist
– Ticlopidine
– Clopidogrel

80. Antiplatelet
• Chronic angina
– Aspirin for life
– ADP receptor antagonist if aspirin intolerable
• Acute coronary syndrome
– Dual antiplatelet

81. Thrombolytic
• Lyse the clot 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 (adenosine diphosphate)
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

86. Primary PCI - 1

87. Aspirated clot

88. Primary PCI - 2

89. PCI of coronary artery
•The narrowing was
openned with a
angioplasty balloon
• A stent was inflated
after the balloon
angioplasty

90. Coronary bypass surgery

91. Coronary artery disease
• ACE inhibitor/Angiotensin receptor blocker
• Beta Blocker
• Calcium channel blocker if not tolerable to beta blocker

92. Treat the concomitant conditions
• Hypertension
• Diabetes Mellitus
• Hyperlipidemia

93. Summary

94. Smoking
Blood
pressure
Cholesterol
Diabetes
mellitus
Other
factors
Atherosclerosis Thrombosis Heart attack
Brain attack
Other
vascular
Development of atherosclerosis

96. Presentation of coronary heart
disease
Asymptomatic Chronic stable
angina
Acute coronary
syndrome (ACS) Death
(MI = Myocardial Infarction)
Unstable angina
Non ST elevation MI
ST elevation MI
Heart failure

97. Acute Coronary Syndrome

98. End of Phase II