Angina is a symptom of coronary artery disease that occurs when the heart muscle does not get enough oxygen-rich blood. It is usually felt as chest pain or discomfort when one engages in physical exertion or is exposed to stress. There are two main types - stable angina, which occurs predictably in relation to activity or stress, and unstable angina, which occurs unpredictably even at rest. Diagnosis involves electrocardiograms, stress tests, and coronary angiography to detect blockages in the arteries. Treatment focuses on lifestyle changes, medications to manage risk factors and symptoms, and procedures like angioplasty or bypass surgery in severe cases.

1. RVS Chaitanya Koppala
Angina

2. Definition
• Angina is the result of myocardial ischemia caused by an imbalance between
myocardial blood supply and oxygen demand.
• It is a common presenting symptom (typically, chest pain) among patients with
coronary artery disease.
• Type of chest pain: pressure or discomfort

3. ADAM.COM

4. Types of Angina
• Angina is classified broadly as stable or unstable, depending on its pattern of
occurrence and severity.
medmovie.com

5. Types of Angina (cont.)
• Stable angina occurs when increased physical activity (e.g., hurrying across a
street or climbing a long stairs) which creates a greater demand for oxygen-rich
blood to reach heart tissue.
• Unstable angina occurs with lesser degrees of exertion or while at rest.
• Unstable angina that occurs at rest is the most serious form.
• Formation of a blood clot at the site of a ruptured plaque in a coronary artery.

6. Pathophysiology
• Myocardial ischemia develops when coronary blood flow
becomes inadequate to meet myocardial oxygen demand.
• This causes myocardial cells to switch from aerobic to anaerobic
metabolism, with a progressive impairment of metabolic,
mechanical, and electrical functions.
• Studies have shown that adenosine may be the main chemical
mediator of anginal pain.
• During ischemia, ATP is degraded to adenosine, which, after
diffusion to the extracellular space, causes arteriolar dilation
and anginal pain.

7. Clinical Presentation
• Angina is a symptom of ischemic heart disease (IHD). Episodes of stable
angina typically are brought on by exertion or emotion and are relieved
with rest.
• An attack of stable angina lasts from 1 to 5 minutes and is described as -
squeezing,
- choking,
- smothering, or
- crushing pressure in the chest.
• Angina pain may radiate to the shoulders, arms, back, neck, or jaw.
• Patients with atherosclerosis also may experience sweating, shortness
of breath (dyspnea).

8. Clinical Presentation (cont.)

9. Diagnosis
• A diagnosis of stable angina is based primarily on symptoms, such as
chest pain.
• A diagnosis of unstable angina is made when there is
- new onset angina that is severe and/or frequent;
- chronic stable angina who develop more frequent, severe, prolonged,
or more easily triggered episodes
- angina at rest.

10. Diagnostic Tests and Procedures
1- ECG (Electrocardiogram)
It detects and records the electrical activity of the heart. Certain electrical
patterns that the ECG detects can suggest whether CAD is likely.
However, some people with angina have a normal ECG.
The ECG is usually normal between attacks. During an attack there may be
a transient ST segment depression.
If the angina is provoked by exertion, an exercise stress ECG should be
performed.

11. Diagnostic Tests and Procedures
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12. Diagnostic Tests and Procedures
2- Stress ECG Testing
Typically, this test involves taking an electrocardiogram (ECG)
before, during, and after exercise on a treadmill or
stationary bicycle. Patients who are at risk for a coronary
event with exercise are, instead, given a drug to increase
the heart rate.

13. Diagnostic Tests and Procedures
3- Coronary angiogram
Is obtained by injecting contrast material into the bloodstream and taking
x-rays of the coronary arteries. This enables the physician to see
blockages, malformations, and stenosis in the vessels.
4- Blood Tests
Blood tests check the levels of certain fats, cholesterol, sugar, and proteins
in blood. Abnormal levels may indicate risk factors for CAD.
Some studies suggest that high levels of CRP (C-reactive protein) in the
blood may increase the risk for CAD and heart attack.

14. Goals of Treatment
• All treatments for people with coronary artery disease have the
same goals:
- to decrease the effects of the disease on the quality
of life and alleviate symptoms.
- to reduce mortality due to CAD progression.

15. Drug Therapy
• Currently, there are three main types of drugs used:
1) Nitrates
2) Beta blockers
3) Calcium channel blockers
• Nitrates or beta blockers are usually preferred for initial treatment of angina, and
calcium channel blockers may be added if needed.

16. Drug Therapy (cont.)
• 1) Nitrates
Nitrates improve blood flow by relaxing and dilating veins and arteries, including
the coronary arteries.
• Examples: nitroglycerin and isosorbide dinitrate.
• Side effects:
The most common side effects of nitrates are headache, lightheadedness,
flushing, and an increase in heart rate.

17. Drug Therapy (cont.)
• 2) Beta blockers
Beta blockers reduce the heart rate, blood pressure, and the
force of contractions, thereby decreasing the amount of oxygen
the heart requires to pump blood.
• Examples: atenolol, metoprolol, nadolol and propranolol.
• Side effects:
Cardiac effects -- worsen heart failure, bradycardia Noncardiac
effects -- constriction of airways, circulatory problems,
Impotence, hallucinations, insomnia, and fatigue

18. Drug Therapy (cont.)
• 3) Calcium channel blockers
Calcium channel blockers dilate arteries and lower blood pressure, which
decreases the force of contractions. They also dilate veins, reducing the amount
of blood returning to the heart, which reduces the workload of the heart.
• Examples: amlodipine, nifedipine, nicardipine, verapamil and diltiazem.
• Side effects:
flushing, dizziness and lightheadedness, headache, peripheral edema and
depression of cardiac function (with non-dihydropyridines)
Patient information — Angina treatment , UpToDate.com (Patient Preview)

19. Other Measures in Managing CAD
• Anticoagulants
• Aspirin: (it helps to prevent blood clotting, keeping the narrowed arteries open
and lowering the risk of a heart attack).
• Treat high blood pressure
• Treat high cholesterol
• Quit smoking
• Lose excess weight
• Reduce stress
• Exercise regularly

20. Other Treatment Options
• Percutaneous Coronary
Intervention (previously called
Angioplasty or Balloon
Angioplasty)
• CABG (Coronary Artery Bypass
Graft Surgery)

21. RVS Chaitanya Koppala
Atherosclerosis

22. Introduction
• Atherosclerosis (also known as Arteriosclerotic Vascular
Disease or ASVD)
• Artery wall thickens (build-up of fatty materials such as
cholesterol)
• Affecting arterial blood vessels, a chronic inflammatory
response in the walls of arteries
Due to the accumulation of macrophage
Promoted by Low-density lipoproteins
Without adequate removal of fats and cholesterol from the
macrophages

23. Hardening or furring of the arteries.
Formation of multiple plaqueswithin the arteries.
Restrict blood flow.
These plaques can also burst, causing a blood clot.
Often considered a heart problem
Affect arteries anywhere in your body.
Atherosclerosis is a preventable and treatable condition.

24. TERMS
• Arteriosclerosis is a general term describing any hardening
(and loss of elasticity) of medium or large arteries
• Arteriolosclerosis is any hardening (and loss of elasticity) of
arterioles (small arteries);
• Atherosclerosis is a hardening of an artery specifically due
to an atheromatous plaque.
• Atherogenic is used for substances or processes that cause
atherosclerosis.
• Atherogenesis is the developmental process of
atheromatous plaques

25. Causes
Atherosclerosis starts with damage or injury to the
inner layer of an artery. The damage may be caused
by:
• High blood pressure
• High cholesterol
• An irritant, such as nicotine
• Certain diseases, such as diabetes

26. Epidemiology
• Estimated 10-year risk of coronary artery disease according
to various combinations of risk factor levels, expressed as
the probability of an event in 10 years.
• According to United States data for the year 2004, for about
65% of men and 47% of women, the first symptom of
atherosclerotic cardiovascular disease is heart attack or
sudden cardiac death (death within one hour of onset of the
symptom).

27. • ATHEROSCLEROSIS is less prevalent in central and south
America, Africa, and Asia. And more prevalent in united
states and Japan.
• The mortality in U.S in 5 times higher than Japan
Epidemiology

28. Pathophysiology
• Atherosclerosis develops as a chronic inflammatory
response of the arterial wall to endothelial injury.
• Lesion progression occurs through interactions of modified
lipoproteins, monocyte-derived macrophages, T-
lymphocytes, and the normal cellular constituent of the
arterial wall.
• The contemporary view of atherosclerosis is expressed by
the response-to-injury hypothesis.

29. Response-to-injury hypothesis
• The following are the
steps involved in the
hypothesis:
1. Chronic endothelial
injury
2. Accumulation of
lipoproteins
3. Monocyte adhesion to
the endothelium
4. SMC proliferations and
ECM (extracellular
matrix) production
5. factor release
6. platelet adhesion

32. Micrograph of an artery that supplies the heart With
significant atherosclerosis and marked luminal narrowing

33. Symptoms
Atherosclerosis develops gradually, typically begins in early
adolescence, and is usually found in most major arteries.
No atherosclerosis symptoms until an artery is so
narrowed or clogged.
Sometimes a blood clot completely obstructs blood flow,
or even breaks apart and causes heart attack or stroke.

34. Atherosclerosis symptoms depend on which arteries are
affected. For example:
Atherosclerosis in heart arteries, have symptoms similar to
those of a heart attack, such as chest pain (angina).
Atherosclerosis in the arteries leading to brain, have
symptoms such as sudden numbness or weakness in your
arms or legs, difficulty speaking or slurred speech, or
drooping muscles in your face.
Atherosclerosis in the arteries in arms and legs, produces
decreased blood flow is called peripheral artery occlusive
disease (PAOD).have symptoms such as leg pain when
walking
Sometimes atherosclerosis causes erectile dysfunction in
men.
Symptoms

35. Symptoms

36. Symptoms

37. Physiologic factors that increase risk
Various anatomic, physiological & behavioral risk factors for atherosclerosis are known.
These can be divided into various categories:, modifiable and non-modifiable.
1. Modifiable
Having diabetes or Impaired glucose tolerance (IGT)
Dyslipoproteinemia (unhealthy patterns of serum proteins carrying
fats & cholesterol):
Tobacco smoking, increases risk by 200% after several pack years
Having high blood pressure, on its own increasing risk by 60%
Elevated serum C-reactive protein concentrations

38. 2. Non modifiable
• Advanced age
• Male sex
• Having close relatives who
have had some complication of
atherosclerosis (CVD/STROKE)
• Genetic abnormalities, e.g.
familial hypercholesterolemia
3. Lesser or uncertain
• Being obese (in particular
central obesity,
• A sedentary lifestyle
• Postmenopausal estrogen
deficiency
• High carbohydrate intake
• Elevated serum levels of
triglycerides
• Elevated serum lipoprotein
concentrations
• Stress or symptoms of
clinical depression
• Hyperthyroidism
• Elevated serum insulin levels
• Short sleep duration
Physiologic factors that increase risk

39. Complications
The complications of atherosclerosis depend on the location
of the blocked arteries. For example:
• Coronary artery disease.
• Carotid artery disease.
• Peripheral artery disease (Arms and legs)
• Aneurysms (any where in body, formation of bulge in
artery)

40. Tests and diagnosis
Doctors may find signs of narrowed, enlarged or hardened
arteries during a physical exam. These include:
A weak or absent pulse below the narrowed area of the
artery
Decreased blood pressure in an affected limb
Whooshing sounds (bruits) over the arteries, heard with a
stethoscope
Signs of a pulsating bulge (aneurysm) in the abdomen or
behind knee
Evidence of poor wound healing in the area where blood
flow is restricted

41. • Blood tests. Lab tests can detect increased levels of cholesterol and
blood sugar that may increase the risk of atherosclerosis.
• Doppler ultrasound. Uses a special ultrasound device (Doppler
ultrasound) to measure blood pressure at various points along arm or
leg. These measurements can help doctor gauge the degree of any
blockages, as well as the speed of blood flow in the arteries.
• Ankle-brachial index. This test can tell if one have atherosclerosis in
the arteries in your legs and feet. Doctor may compare the blood
pressure in ankle with the blood pressure in the arm. This is known as
the ankle-brachial index. An abnormal difference may indicate
peripheral vascular disease, which is usually caused by atherosclerosis.
Tests and diagnosis

42. • Electrocardiogram (ECG). An electrocardiogram records electrical
signals as they travel through your heart. An ECG can often reveal
evidence of a previous heart attack or one that's in progress.
• Angiogram. To better view blood flow through heart, brain, arms or
legs, doctor may inject a special dye into your arteries before an X-ray.
This is known as an angiogram. The dye outlines narrow spots and
blockages on the X-ray images.
• Other imaging tests. doctor may use ultrasound, a computerized
tomography (CT) scan or a magnetic resonance angiogram (MRA) to
study the arteries. These tests can often show hardening and
narrowing of large arteries, as well as aneurysms and calcium deposits
in the artery walls.
Tests and diagnosis

43. Lifestyle changes, such as eating a healthy diet and
exercising, are often the first line of defense in treating
atherosclerosis.
But sometimes, medication or surgical procedures may be
recommended as well.
Various drugs can slow — or sometimes even reverse
Cholesterol medications. Aggressively lowering low-
densitylipoprotein (LDL) cholesterol, the "bad" cholesterol,
can slow, stop or even reverse the buildup of fatty deposits
in arteries. Boosting your high-density lipoprotein (HDL)
cholesterol, the "good" cholesterol, may help, too.
cholesterol medications includes drugs known as statins
and fibrates.
Treatments and drugs

44. • Anti-platelet medications. Doctors may prescribe anti-
platelet medications, such as aspirin, to reduce the
likelihood that platelets will clump in narrowed arteries,
form a blood clot and cause further blockage.
• Anticoagulants. An anticoagulant, such as heparin or
warfarin (Coumadin), can help thin blood to prevent
clots from forming.
• Blood pressure medications. Medications to control
blood pressure — such as beta blockers, angiotensin-
converting enzyme (ACE) inhibitors and calcium channel
blockers — can help slow the progression of
atherosclerosis
Treatments and drugs

45. Other medications.
Such as diabetes.
Leg pain during exercise, are prescribed.
Symptoms or a blockage that threatens muscle or skin
tissue survival, you may be a candidate for one of the
following surgical procedures
Treatments and drugs

46. Angioplasty. In this procedure, your doctor inserts a long,
thin tube (catheter) into the blocked or narrowed part of
your artery.
A mesh tube (stent) is usually left in the artery to help
keep the artery open. Angioplasty may also be done with
laser technology.
Endarterectomy. In some cases, fatty deposits must be
surgically removed from the walls of a narrowed artery.
When the procedure is done on arteries in the neck (the
carotid arteries), it's known as carotid endarterectomy.
Treatments and drugs

47. Thrombolytic therapy. If you have an artery that's
blocked by a blood clot, your doctor may insert a clot-
dissolving drug into your artery at the point of the clot
to break it up.
Bypass surgery. Your doctor may create a graft bypass
using a vessel from another part of your body or a tube
made of synthetic fabric. This allows blood to flow
around the blocked or narrowed artery.
Treatments and drugs

48. Lifestyle and home remedies
Lifestyle changes can help prevent or slow the progression
of atherosclerosis.
• Stop smoking.
• Exercise most days of the week.
• Eat healthy foods
• Manage stress
• Manage the condition of high cholesterol, high blood
pressure, diabetes or other chronic disease

49. References:
• Harrison’s principle of internal medicine, 17th
edition.
• Robbins basic pathology, 8th edition.
• www.wekiepedia.com/atherosclerosis
• www.mayoclinic.com/atherosclerois

50. THANK YOU