Coronary heart disease is caused by inadequate blood flow to the heart muscle due to atherosclerotic plaques narrowing the coronary arteries or other non-atherosclerotic causes. The most common cause is coronary artery disease (CAD) due to plaque accumulation over time from risk factors like smoking, hypertension, diabetes, and hypercholesterolemia. Clinical manifestations range from stable angina to heart attack. Diagnosis involves ECG, cardiac enzymes, stress testing, and coronary angiography. Treatment depends on severity and includes medical management, percutaneous interventions, bypass surgery, and risk factor modification.

1. Coronary heart disease
Impaired cardiac function
due to inadequate
coronary circulation

2. Commonest cause- CAD
End result of accumulation of
atheromatous plaques in
coronary arteries

3. Non-atherosclerotic causes
 Coronary vasospasm- Prinzmetal angina
 Cardiac syndrome X- common in women
 Severe LV hypertrophy
 Severe aortic stenosis or regurgitation
 Congenital coronary artery anomaly
 Coronary artery emboli/dissection
 Increased cardiac demand- tachycardia,
anemia, hyperthyroidism

4. Risk factors for
atherosclerosis
 Non-modifiable- age, sex, family history
 Modifiable-
 Smoking
 Hypercholesterolemia- LDL, lipoprotein a
 Hypertension- systolic > diastolic
 Hyperglycemia- diabetes mellitus
 Type A behaviour- stress
 High fibrinogen, factor VII
 Hyperhomocysteinemia
 Obesity, sedentary lifestyle
 CRI

5. Pathophysiology
 Atherosclerosis is nearly universal & starts before
adulthood, leading to plaque formation
 Plaques cause narrowing of coronary arteries
 Stable plaque causes predictable angina
 Unstable plaque ruptures, activating clotting system &
thrombus formation, that impairs coronary blood flow
causing unstable angina or MI
 MI heals with scarring, causing impairing contractility
& increasing stiffness, leading to HF- acute/chronic
 Ischemic areas & scars are prone to cause
ventricular arrythmias, leading to sudden death

6. Manifestations
 Asymptomatic
 Angina-
 Acute- unstable- unpredictable
 Chronic- stable- predictable
 Myocardial infarction-
 Non ST elevated- NSTEMI
 ST elevated- STEMI
 Acute LVF
 Ischemic cardiomyopathy- CHF
 Sudden cardiac death

7. Clinical presentation
 Angina pectoris-
 Precordial/retrosternal/epigastric pain
 Described as tightness, squeezing, choking, indigestion
 Duration- <20 mins
 Radiation to left arm, shoulder, jaw
 Precipitated by exertion, stress, meal, cold, sex
 Relieved by rest or sublingual nitroglycerin
 Associated SOB, sweating, nausea, dizziness/syncope
 Unstable angina-
 Angina at rest, new-onset, more severe, increased frequency
 Myocardial infarction-
 Duration- >20 mins, not relieved by NTG

8. Evaluation
 Examination- HR, BP,
±S3/S4, murmur of MR
 Ix-
 Disease- ECG-ST elevation/depression, CxR,
Stress test-
TMT/radionuclide/ECHO,
ECHO- regional wall-motion abnormality,
Coronary angiography- CT or conventional, ±IVUS
 Risk factors- FBS, lipid profile, creatinine
 Precipitating factors- Hb, TSH

9. TMT- Treadmill test
 Bruce protocol-
 Increases treadmill speed & elevation every 3 minutes
 Indication-
 To confirm diagnosis of angina & determine severity
 To assess prognosis in patients with known CAD
 Screen those at high risk of CAD
 Interpretation-
 >1 mm flat or downsloping ST depression
 Severe disease- >2 mm depression, <6 mins. of exercise,
HR <70% predicted for age & hyper/hypotension

10. Coronary angiography
 For definitive diagnosis of CAD
 Indication- if PTCA/CABG an option-
 Limiting stable angina on adequate medical Rx
 High-risk disease- ACS or high-risk TMT
 Concomitant aortic valve disease
 Older patients undergoing valve surgery
 Recurrence of angina after PTCA/CABG
 Cardiac failure with surgically correctable lesion
 Survivors of SCD or VT
 Chest-pain or cardiomyopathy of unknown etiology

11. Treatment
 Medical-
 Aspirin- anti-thrombotic-1° & 2° prevention
 β-blockers- decrease cardiac workload- 2° prevention
 Statins- plaque stabilization & reduction- 2° prevention
 ACEI- cardiac remodelling- MI/HF
 Percutaneous- PTCA ± stent placement
 Bypass- CABG
 Experimental-
 Angiogenic growth factors- FGF-1, VEGF
 Stem-cell therapy
 Risk factor modification

12. Risk factor modification
 Quit smoking
 Control HT
 Control DM
 Control LDL
 Reduce stress
 Reduce weight
 Active lifestyle

13. Complication
 Recurrent ischemia- more after NSTEMI than STEMI
 Arrythmia- bradycardia, AV block, VT
 Shock- urgent PCI, ± IABP support
 Acute MR/VSD- supportsurgical correction
 Myocardial rupture- kills
 Heart failure- diuretics, nitrates, dobutamine
 Aneurysm- surgery, if required
 Mural thrombus ± embolization-
UFH/LMWHwarfarin

14. Chronic stable angina
 Angina occuring predictably on exertion &
relieved by rest or sublingual NTG
 Normal troponin & CK-MB
 ECG-
 Resting ECG- normal
 During anginal episode-
>1 mm ST depression ± T wave
flattening/inversion (ST
elevation seen in Prinzmetal angina)
 ECHO- for RWMA & LVEF
 Exercise testing- TMT
 Coronary angiography, if indicated

15. Treatment
 Sublingual NTG- for acute pain
 Prevention of attacks-
 Treat/avoid aggravating factors
 Aspirin (alternative- clopidogrel)
 Statins
 β-blockers
 ± long-acting nitrates
 ± CCB
 Risk factor modification

16. Revascularization
 Indication-
 Symptomatic despite adequate medical Rx
 Left main coronary artery stenosis
 Triple vessel disease with LVEF <50%
 Unstable angina
 Post-MI angina or +ve TMT
 Modalities-
 PCI- with stent- bare metal/drug eluting- placement
 CABG- preferred for L main/TVD with low
LVEF/T2DM

17. Acute coronary syndrome- ACS
 Unstable angina & myocardial infarction
 Unstable angina- cardiac markers- normal
 Angina at rest, new-onset, more severe, increased frequency
 With ST depression on ECG & normal Trop-T/I or CK-MB
 Myocardial infarction- cardiac markers- high
 Angina- lasts longer & not responsive to S/L NTG
 Rise of cardiac biomarkers- Trop-T/I & CK-MB
 With ECG changes- new Q waves/LBBB,
non-ST elevated-NSTEMI or ST elevated-
STEMI
 ECHO- new loss of viable myocardium or new RWMA

18. Recoverable myocardium
Hibernating- chronic ischemia
Stunned- post-MI
Evaluation- ECHO

19. Treatment of NSTE ACS
 Admit- rest, monitoring, ?oxygen
 Aspirin- 325 mg
 Clopidogrel- 300 mg stat75 mg OD
 Anticoagulation- UFH/LMWH
 Nitrates- for symptomatic relief
 β-blockers- as tolerated
 CCB- as add-on to nitrates & β-blockers
 Statins
 GP IIb/IIIa inhibitors- for intended early cath/PCI or
for high-risk patients- eptifibatide, tirofiban, abciximab

20. Indication for early angiography
All patients with ACS, except
those with normal stress test-
TMT/ECHO/radionuclide

21. STEMI
 Common in early morning
 ~1/2 have preceding angina- ignored
 1/3rd
without chest-pain,
specially diabetics
 e/o HF- poor prognosis
 Trop T/I- early MI, CK-MB- reinfarction

22. Treatment
 Admit- rest, morphine, ?oxygen, monitoring
 Aspirin + Clopidogrel
 β- blockers- early, if no contraindications
 ACEI- early, if no hypotension
 Statins
 Reperfusion-
within 12 hours of onset, sooner the better
 Options- for reperfusion
 1° angioplasty- with stenting & GP IIb/IIIa inhibitors
 Thrombolytic therapy- streptokinase, alteplase, tenecteplase-
followed by anticoagulation x 7 days

23. Post-infarction- no angiography
No complications
Preserved LVEF >50%
No exercise induced ischemia

24. Major differences
 Unstable angina-
 Trop T/I & CK-MB- normal
 Rx- Asp + Clopidogrel + UFH/LMWH ± GP IIb/IIIa inhibitors
 Early coronary angiography- Dx & Rx
 NSTEMI-
 Trop T/I & CK-MB- raised
 Rx- as for unstable angina
 Early coronary angiography
 STEMI-
 Trop T/I & CK-MB- raised
 Rx- Asp ± Clopidogrel + 1° PCI/Thrombolysis
 No angiography- post-MI normal LVEF & normal stress test