This document discusses the pathophysiology of myocardial ischemia and infarction. It describes how myocardial oxygen demand can exceed supply, leading to ischemia. Factors that determine oxygen demand and supply are explored, including heart rate, contractility, wall tension, coronary blood flow, oxygen carrying capacity of blood, and autoregulatory resistance in arterioles. The progression and vulnerability of atherosclerotic plaque is summarized. Clinical syndromes like stable angina and acute coronary syndromes (unstable angina and myocardial infarction) are defined and their presentations, diagnoses, and treatment approaches are overviewed.
Atherosclerosis - Definition - Risk Factors - Lesser and Non Quantitated risk factors - Arterial wall - The development of Atherosclerosis - Many Features of the injury Hypothesis - The process of Atherogenesis - Pathogenesis in short - Morphology of Atheroma - Components of Atheromatous Plaque (MP) - Complications and clinical significance - Cardiovascular risk and its assessment.
Atherosclerosis - Definition - Risk Factors - Lesser and Non Quantitated risk factors - Arterial wall - The development of Atherosclerosis - Many Features of the injury Hypothesis - The process of Atherogenesis - Pathogenesis in short - Morphology of Atheroma - Components of Atheromatous Plaque (MP) - Complications and clinical significance - Cardiovascular risk and its assessment.
Rheumatic heart disease is a condition in which the heart valves have been permanently damaged by rheumatic fever. The heart valve damage may start shortly after untreated or under-treated streptococcal infection such as strep throat or scarlet fever.
Ischemia is defined as a condition of inadequate blood supply to an area of tissue.
Infarction- Localized area of ischemic necrosis in an organ or tissue resulting most often from reduction of arterial blood supply or occasionally its venous drainage
Public Health Significance- Long-term exposure to other lung irritants also is a risk factor for COPD leading to IHD. Examples of other lung irritants include secondhand smoke, air pollution, and chemical fumes and dust from the environment or workplace.
More than 66% of U.S. adults are categorized as overweight or obese, and the prevalence of obesity is increasing rapidly in most of the industrialized world.
Children and adolescents also are becoming more obese, indicating that the current trends will accelerate over time.
Obesity is associated with an increased risk of multiple health problems, including hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, nonalcoholic fatty liver disease, degenerative joint disease, and some malignancies.
Thus, it is important for physicians to identify, evaluate, and treat patients for obesity and associated comorbid conditions.
Rheumatic heart disease is a condition in which the heart valves have been permanently damaged by rheumatic fever. The heart valve damage may start shortly after untreated or under-treated streptococcal infection such as strep throat or scarlet fever.
Ischemia is defined as a condition of inadequate blood supply to an area of tissue.
Infarction- Localized area of ischemic necrosis in an organ or tissue resulting most often from reduction of arterial blood supply or occasionally its venous drainage
Public Health Significance- Long-term exposure to other lung irritants also is a risk factor for COPD leading to IHD. Examples of other lung irritants include secondhand smoke, air pollution, and chemical fumes and dust from the environment or workplace.
More than 66% of U.S. adults are categorized as overweight or obese, and the prevalence of obesity is increasing rapidly in most of the industrialized world.
Children and adolescents also are becoming more obese, indicating that the current trends will accelerate over time.
Obesity is associated with an increased risk of multiple health problems, including hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, nonalcoholic fatty liver disease, degenerative joint disease, and some malignancies.
Thus, it is important for physicians to identify, evaluate, and treat patients for obesity and associated comorbid conditions.
This presentation consists of various approaches to treat hypertension depending on severity. It also include treatment according to international guidelines. Classification and brief description of each antihypertensive agent has been mentioned.
Disorders of Cardiovascular Function.pptxgadnyabuto1
Cardiovascular disorders, also known as cardiovascular diseases (CVDs), refer to a group of conditions that affect the heart and blood vessels. These disorders can range from mild to severe and can have a significant impact on an individual's health and quality of life. Here is a detailed description of some common cardiovascular disorders:
Coronary Artery Disease (CAD): CAD is the most prevalent cardiovascular disorder and occurs when the blood vessels that supply the heart muscle with oxygen and nutrients become narrowed or blocked. This narrowing is usually caused by the buildup of plaque consisting of cholesterol, fat, and other substances. CAD can lead to chest pain (angina), heart attack (myocardial infarction), or heart failure if the blood flow to the heart is severely restricted.
Hypertension (High Blood Pressure): Hypertension is a chronic condition characterized by elevated blood pressure levels. It puts additional strain on the heart and blood vessels, increasing the risk of heart disease, stroke, and other complications. Hypertension often has no noticeable symptoms, which is why it is often referred to as the "silent killer." Lifestyle modifications, such as a healthy diet, regular exercise, and medication, are commonly used to manage hypertension.
Heart Failure: Heart failure occurs when the heart is unable to pump blood efficiently to meet the body's needs. It can result from various underlying conditions, including CAD, high blood pressure, heart valve disorders, or previous heart attacks. Symptoms of heart failure may include fatigue, shortness of breath, fluid retention (edema), and reduced exercise tolerance. Treatment options include medications, lifestyle changes, and in severe cases, surgical interventions such as heart transplantation.
Arrhythmias: Arrhythmias are abnormal heart rhythms that can occur due to disruptions in the electrical signals that coordinate the heartbeat. This can cause the heart to beat too fast (tachycardia), too slow (bradycardia), or irregularly. Common types of arrhythmias include atrial fibrillation, atrial flutter, and ventricular tachycardia. Some arrhythmias may not require treatment, while others may be managed with medications, electrical cardioversion, or other procedures.
Stroke: Although not exclusively a cardiovascular disorder, strokes often occur due to problems with blood vessels supplying the brain. Ischemic strokes are the most common type and are caused by blockages in the arteries leading to the brain. Hemorrhagic strokes occur when a blood vessel in the brain ruptures. Strokes can lead to long-term disability or even death, emphasizing the importance of recognizing and managing risk factors such as hypertension, smoking, and high cholesterol.
Peripheral Artery Disease (PAD): PAD occurs when the blood vessels outside the heart, usually those supplying the legs and arms, become narrowed or blocked. This can result in reduced blood flow, causing pain, numbness, or weakness in
The term ischemic heart disease (IHD) describes a group of clinical syndromes characterized by myocardial ischemia, an imbalance between myocardial blood supply and demand.
Because the fundamental pathophysiologic defect in the ischemic myocardium is inadequate perfusion, ischemia is associated not only with insufficient oxygen supply, but also with reduced availability of nutrients and inadequate removal of metabolic end products.
Ischemic heart disease (IHD) caused by atherosclerosis of the epicardial vessels leading to coronary heart disease (CHD) is the main etiology of IHD.
Leading cause of death
Resulting from myocardial ischemia—an imbalance between the supply (perfusion) and demand of the heart for oxygenated blood.
90% of cases, the cause of myocardial ischemia is reduced blood flow due to obstructive atherosclerotic lesions in the coronary arteries.
IHD is often termed coronary artery disease (CAD) or coronary heart disease.
There is a long period (up to decades) of silent, slow progression of coronary lesions before symptoms appear.
IHD are only the late manifestations of coronary atherosclerosis that may have started during childhood or adolescence
Myocardial infarction, the most important form of IHD, in which ischemia causes the death of heart muscle.
Angina pectoris, in which the ischemia is of insufficient severity to cause infarction, but may be a harbinger of MI.
Chronic IHD with heart failure.
Sudden cardiac death.
The dominant cause of the IHD syndromes is insufficient coronary perfusion relative to myocardial demand, due to • Chronic, progressive atherosclerotic narrowing of the epicardial coronary arteries, and • Variable degrees of superimposed acute plaque change, thrombosis, and vasospasm
Clinical manifestations of coronary atherosclerosis are generally due to • Progressive narrowing of the lumen leading to stenosis (“fixed” obstructions) or • Acute plaque disruption with thrombosis, both of which compromise blood flow.
A fixed lesion obstructing 75% or greater of the lumen is generally required to cause symptomatic ischemia precipitated by exercise (most often manifested as chest pain, known as angina)
Obstruction of 90% of the lumen can lead to inadequate coronary blood flow even at rest.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
4. Basic Principles
myocardial cells have to do only 2 things:
contract and relax; both are aerobic, O2
requiring processes
oxygen extraction in the coronary bed is
maximal in the baseline state; therefore to
increase O2 delivery, flow must increase
large visible epicardial arteries are conduit
vessels not responsible for resistance to flow
(when normal)
5. Basic Principles
small, distal arterioles make up the major
resistance to flow in the normal state
atherosclerosis (an abnormal state) affects
the proximal, large epicardial arteries
once arteries are stenotic (narrowed)
resistance to flow increases unless distal,
small arterioles are able to dilate to
compensate
8. MVO2 (Myocardial Oxygen Demand)
Increases directly in proportion to heart
rate
Increases with increased contractility
Increases with increased Wall Tension:
i.e. increases with increasing preload
or afterload
11. Wall Tension
Is related to Pressure x Radius
Wall Thickness
Defined as: Force per unit area generated in the LV
throughout the cardiac cycle
Afterload - LV systolic pressure
Preload - LV end-diastolic pressure or volume
16. Endocardium vs Epicardium
Greater shortening / thickening, higher
wall tension: increased MVO2
Greater compressive resistance
? Decreased Perfusion Pressure
Less collateral circulation
Net Result is more compensatory
arteriolar vasodilatation at baseline and
therefore decreased CFR
17. Autoregulatory Resistance
Major component of resistance to flow
Locus at arteriolar level
Adjusts flow to MVO2
Metabolic control
Oxygen
Adenosine , ADP
NO (nitric oxide)
Lactate , H+
Histamine, Bradykinin
18. Autoregulatory Resistance
Myocardial muscle cell - produces byproducts
of aerobic metabolism (lactate,adenosine, etc)
Vascular endothelial cell (arteriole) - reacts to
metabolic byproducts
Vascular smooth muscle cell (arteriole) -
signaled by endothelial cell to contract (vessel
constriction) or relax (vessel dilation)
Involves 3 different cells
19. Autoregulation of Coronary
Blood Flow
Oxygen
Acts as
vasoconstrictor
As O2 levels drop
during ischemia: pre-
capillary vasodilation
and increased
myocardial blood
supply
Adenosine
Potent vasodilator
Prime mediator of
coronary vascular
tone
Binds to receptors on
vascular smooth
muscle, decreasing
calcium entry into cell
20. Adenosine
During hypoxemia, aerobic metabolism
in mitochondria is inhibited
Accumulation of ADP and AMP
Production of adenosine
Adenosine vasodilates arterioles
Increased coronary blood flow
23. Coronary Flow Reserve
Arteriolar autoregulatory vasodilatory capacity in
response to increased MVO2 or pharmacologic
agents
Expressed as a ratio of Maximum flow / Baseline
flow
~ 4-5 / 1 (experimentally)
~ 2.25 - 2.5 (when measured clinically)
24. Coronary Flow Reserve
Stenosis in large epicardial (capacitance) vessel →
decreased perfusion pressure → arterioles
downstream dilate to maintain normal resting flow
As stenosis progresses, arteriolar dilation becomes
chronic, decreasing potential to augment flow and
thus decreasing CFR
Endocardial CFR < Epicardial CFR
As CFR approaches 1.0 (vasodilatory capacity
“maxxed out”), any further decrease in PP or increase
in MVO2 → ischemia
27. Coronary Steal
Vasodilator Rx (Ado)
R2 decreases
Flow increases to A
R3 - no reserve
Increased flow across
R1 GRT P1-2
No change in P1
P2
Flow to B is
dependant on P2 and
A
B
Sub-epicardium
Sub-endocardium
32. Atherosclerotic Plaque
Evolution from Fatty Streak
Fatty streaks present
in young adults
Soft atherosclerotic
plaques most
vulnerable to
fissuring/hemorrhage
Complex interaction of
substrate with
circulating cells
(platelets,
macrophages) and
neurohumoral factors
38. Stable Angina - Symptoms
mid-substernal chest pain
squeezing, pressure-like in quality (closed fist =
Levine’s sign)
builds to a peak and lasts 2-20 minutes
radiation to left arm, neck, jaw or back
associated with shortness of breath, sweating, or
nausea
exacerbated by exertion, cold, meals or stress
relieved by rest, NTG
52. Acute Coronary Syndrome
Terminology
Pathophysiology of all 3 is the same
Unstable Angina (UA)
ST depression, T Wave inversion or normal
No enzyme release
Non-Transmural Myocardial Infarction (NTMI or SEMI)
ST depression, T Wave inversion or normal
No Q waves
CPK, LDH + Troponin release
Transmural Myocardial Infarction (AMI)
ST elevation
+ Q waves
CPK, LDH + Troponin release
53. Pathophysiology of the Acute
Coronary Syndrome (UA,MI)
Plaque vulnerability and extrinsic
triggers result in plaque rupture
Platelet adherence, aggregation and
activation of the coagulation cascade
with polymerization of fibrin
Thrombosis with sub-total (UA, NTMI) or
total coronary artery occlusion (AMI)
58. Acute Coronary Syndrome
Unstable Angina / Myocardial Infarction
Symptoms
new onset angina
increase in frequency, duration or
severity
decrease in exertion required to provoke
any prolonged episode (>10-15min)
failure to abate with >2-3 S.L. NTG
onset at rest or awakening from sleep
59. Unstable Angina -
High Risk Features
prolonged rest pain
dynamic EKG changes (ST depression)
age > 65
diabetes mellitus
left ventricular systolic dysfunction
angina associated with congestive heart
failure, new murmur, arrhythmias or
hypotension
elevated Troponin i or t
60. Unstable Angina / NTMI
Pharmacologic Therapy
ASA and Heparin beneficial for acute
coronary syndromes ( UA, NTMI, AMI)
Decrease MVO2 with Nitrates, Beta-
blockers, Ca channel blockers, and Ace
inhibitors
consider platelet glycoprotein 2b / 3a
inhibitor and / or low molecular weight
heparin
61. Anti-Platelet Therapy
Three principle pathways of platelet
activation with >100 agonists: ( TXA2,
ADP, Thrombin )
Final common pathway for platelet
activation / aggregation involves
membrane GP II b / III A receptor
Fibrinogen molecules cross-bridge
receptor on adjacent platelets to form a
scaffold for the hemostatic plug
62. Platelet GP IIB/ IIIA Inhibitors
with Acute Coronary Syndromes
Odds Ratios and 95% CI for Composite Endpoint
( Death,Re- MI at 30days )
0.2 1 4
PURSUIT
PRISM
(vs Heparin)
PRISM PLUS
(+ Heparin)
PARAGON
(high dose)
15.7 14.2
7.1 5.8
11.9 8.7
11.7 12.0
Placebo (% ) Rx ( % )
Rx better Placebo better
63. Low Molecular Weight Heparin
in Acute Coronary Syndromes
Odds Ratios and 95% CI for Composite Endpoint
( Death, MI, Re-angina or Revasc at 6-14 days )
0.2 1 4
FRISC
FRIC
ESSENCE
TIMI 11b
10.3 5.4
7.6 9.3
19.8 16.6
16.6 14.2
UH / Placebo Rx
(%) (%)
LMWH Better UH Better
64. Acute Myocardial Infarction
total thrombotic occlusion of epicardial coronary
artery → onset of ischemic cascade
prolonged ischemia → altered myocardial cell
structure and eventual cell death (release of enzymes
- CPK, LDH, Troponin)
altered structure → altered function (relaxation and
contraction)
consequences of altered function often include
exacerbation of ischemia (ischemia begets ischemia)
65. Acute Myocardial Infarction
wavefront phenomenon of ischemic evolution -
endocardium to epicardium
If limited area of infarction → homeostasis achieved
If large area of infarction (>20% LV ) → Congestive heart
failure
If larger area of infarction (>40% LV) → hemodynamic collapse
67. Acute Myocardial Infarction
Non-transmural /
sub-endocardial
Non-occlusive
thrombus or
spontaneous re-
perfusion
EKG – ST depression
Some enzymatic
release – troponin i
most sensitive
Transmural
total, prolonged
occlusion
EKG - ST elevation
Rx - Thrombolytic
Therapy or Cath
Lab / PTCA
68. Cardiac enzymes: overview
Legend: A. Early CPK-MB isoforms after acute MI
B. Cardiac troponin after acute MI
C. CPK-MB after acute MI
D. Cardiac troponin after unstable angina
70. Diagnosis of MI:
Role of troponin i
♥ Troponin I is highly
sensitive
♥ Troponin I may be
elevated after
prolonged
subendocardial
ischemia
♥ See examples below
71. Causes of Troponin elevation
Any cause of prolonged (>15 – 20
minutes) subendocardial ischemia
Prolonged angina pectoris
Prolonged tachycardia in setting of CAD
Congestive heart failure (elevated LVEDP
causing decreased subendocardial
perfusion)
Hypoxia, coupled with CAD
“aborted” MI (lytic therapy or spontaneous
clot lysis)
72. EKG diagnosis of MI
ST segment
elevation
ST segment
depression
T wave inversion
Q wave formation
73. Consequences of Ischemia
(Ischemia begets Ischemia)
chest pain
systolic dysfunction (loss of contraction)
decrease cardiac output
decrease coronary perfusion pressure
diastolic dysfunction (loss of relaxation)
higher pressure (PCWP) for any given volume
dyspnea, decrease pO2, decrease O2 delivery
increased wall tension (increased MVO2)
All 3 give rise to stimulation of sympathetic nervous system with subsequent
catecholamine release- increased heart rate and blood pressure (increased MVO2)
75. Treatment of Acute Myocardial Infarction
aspirin, heparin, analgesia, oxygen
reperfusion therapy
thrombolytic therapy (t-PA, SK, n-PA, r- PA)
new combinations ( t-PA, r-PA + 2b / 3a inhib)
cath lab (PTCA, stent)
decrease MVO2
nitrates, beta blockers and ACE inhibitors
for high PCWP - diuretics
for low Cardiac Output - pressors (dopamine, levophed,
dobutamine; IABP; early catheterization
76. TIMI Flow Grades
TIMI 0 Flow = no penetration of contrast beyond stenosis
(100% stenosis, occlusion)
TIMI 1 Flow = penetration of contrast beyond stenosis
but no perfusion of distal vessel
(99% stenosis, sub-total occlusion)
TIMI 2 Flow = contrast reaches the entire distal vessel but either
at a decreased rate of filling or clearing versus
the other coronary arteries (partial perfusion)
TIMI 3 Flow = contrast reaches the distal bed and clears at an
equivalent rate versus the other coronary arteries
(complete perfusion)
77. GUSTO
7.2 7.4
6.3
7.0
0
2
4
6
8
10
SK + SQ
Heparin
SK + IV
Heperan
Accel. t-PA t-PA + SK
N: 9,796 10,376 10,344 10,327
p-values t-PA vs. t-PA + SK 0.04
t-PA vs. SK (IV) 0.003
t-PA vs. SK (SQ) 0.009
t-PA vs. Combo SK 0.001
30 Day Mortality
78. GUSTO
0
20
40
60
80
100
SK+ SQ
Heparin
SK + IV
Heparin
Accel. t-PA t-PA + SK
TIMI 3 TIMI 2
p < 0.001 p < 0.001
56 % 61 %
81 % *
73 %
% of Patients
N: 295 282 291 297
p = < 0.001 for Accelerated t-PA vs. all other arms
90 min Patency
80. Coronary Steal
Role of Collaterals
P1 P1P2 P2
Rest Adenosine
Assumptions
Collateral resistance
P1 drops with vasodil
P2 bed with no vaso
dilator reserve
Flow Flow
collateral collateral