Clopidogrel, Prasugrel, Ticagrelor

1. Coronary Heart Disease
In coronary heart disease atherosclerosis
develops in the coronary artery causing them
to become narrowed or blocked, blood flow to
the area of the heart supplied by the artery is
reduced. The area becomes ischemic and
injured and myocardial infarction may result.
Ms. Shany Thomas, Asst.Professor, MSN

2. Etiology
The primary cause is inflammation and lipid
deposition in the wall of the artery

3. Risk Factors
Non modifiable
•Gender
•Heredity
•Age
Modifiable
•High blood pressure
•High blood cholesterol
•Smoking
•Physical inactivity
•Obesity
•Diabetes
Contributing factors
•Response to stress
•Homocysteine levels
•Inflammatory responses
•Menopause

4. PATHOPHYSIOLOGY
CAD is a progressive disease. It is initiated by the
edothelial injury caused by inflammatory response in
the intimal layer and deposition of lipid in to the wall.
The process has been shown to occur in 5 phases that
include 6 progressive type of lesions.

8. Phase I
• Present in 30 yrs of age
• Clinically silent lesions of type I to type III
Type I: Microscopic changes of smooth muscles
Type II: Development of fatty streaks
Type III: preatheroma- deposition of more lipids

9. Phase II
• Development of vulnerable lesions
Type IV: Atheroma- accumulation of large
amount of extracellular lipids forms lipid core
Type V : fibrous connective tissue forms a thin
cap over the atheroma

10. Phase III
• Development of complicated lesions
Type VI: Fissure in the wall, formation of
hematoma and thrombus

11. Phase IV
• Thrombus blocks significantly
Phase V
• Plaque calcifies

13. Clinical features
Signs &
Symptoms
None
Chest
Pain
Shortness
Of Breath
Heart
Attack
• None: This is referred to as silent ischemia.
Blood to the heart may be restricted due to
CAD, but doesn’t produce symptoms.
• Chest pain: If the coronary arteries can’t
supply enough blood to meet the oxygen
demands of the heart, the result may be
chest pain called angina.
• Shortness of breath: Some people may not
be aware they have CAD until they develop
symptoms of congestive heart failure-
extreme fatigue with exertion, shortness of
breath and swelling in feet and ankles.
• Heart attack: Results when an artery to the
heart muscle becomes completely blocked.

14. Diagnostic studies
• Electrocardiography
• Echo cardiography
• Stress testing
• Cardiac catheterization

15. ECG Changes

16. Exercise stress testing
• A stress test monitors the patient's heart rhythms, blood
pressure, and clinical status.
• It can tell how well the heart handles work and if parts
of the heart have decreased blood supply.
A typical stress test involves:
• The patient walks on a treadmill or rides a stationary
bicycle. Exercise continues until the heart is beating at
least 85% of its maximum rate, until symptoms of heart
trouble occur, or the patient simply wants to stop.
• An ECG is used to monitor heart rhythms during a
stress test. An echocardiogram or more advanced
imaging technique may also be used to visualize the
actions of the heart and blood flow.

17. Interpretation
• Exercise capacity.
• ST waves on the ECG
• Heart rate
• Changes in systolic blood pressure.
• Oxygen levels may also be measured

20. Cardiac catheterization
• Cardiac catheterization is the insertion of
a catheter into a chamber or vessel of the heart.
This is done both for diagnostic and
interventional purposes.
• Subsets of this technique are mainly coronary
catheterization, involving the catheterization of
the coronary arteries, and catheterization of
cardiac chambers and valves of the cardiac
system.

22. Management
1. Reduce the risk factors:
2. Restore blood supply:
 Angioplasty (PTCA)
 Coronary atherectomy
 Stenting
 Bypass surgery
 Laser Heart Surgery or Trans myocardial
revascularization

23. Reducing risk factors
•Regular medical checkups.
•Control of blood pressure.
•Control of blood cholesterol.
•Smoking cessation.
•Exercise regularly.
•Maintain a healthy weight.
•Eat a heart-healthy diet.
•Manage stress.
•Life style modification

24. PTCA
• A balloon catheter is passed through the guiding
catheter to the area near the narrowing. A guide wire
inside the balloon catheter is then advanced through
the artery until the tip is beyond the narrowing.
• The angioplasty catheter is moved over the guide wire
until the balloon is within the narrowed segment.
• Balloon is inflated, compressing the plaque against the
artery wall
• once plaque has been compressed and the artery has
been sufficiently opened, the balloon catheter will be
deflated and removed.

27. Stenting
• a stent is introduced into a blood vessel on a
balloon catheter and advanced into the blocked
area of the artery
• the balloon is then inflated and causes the
stent to expand until it fits the inner wall of the
vessel, conforming to contours as needed
• the balloon is then deflated and drawn back
• The stent stays in place permanently, holding
the vessel open and improving the flow of
blood.

29. Directional coronary Atherectomy

30. Coronary Artery Bypass Graft
• Construction of new conduits.
GRAFTS:
 Saphenous vein
 Internal mammary artery
 Radial artery
 Gastroepiploic artery
 Inferior epigastric artery

32. Laser Heart Surgery or Trans myocardial
revascularization
• High powered laser is used to open up
channels in the heart through a relatively small
chest incision by punching holes in the beating
heart which is believed to promote
angiogenesis.

34. Medical management
• Antiplatelet therapy: Aspirin, Heparin