CAD-ACS
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Presentation on Spectrum of coronary artery disease, clinical features and management
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CAD-ACS
- 1. CORONARY ARTERY DISEASE Dr.S.Vinoth Kumar Assistant Professor Internal Medicine IGMC&RI
- 2. CAD Risk factors and Pathophysiology Clinical spectrum Clinical features Investigations and treatment Complications of MI 5/24/2021 2 MEU_IGMC&RI_ITP
- 3. Traditional risk factors: -Age -Male gender -Dyslipidemia High LDL cholesterol Low HDL cholesterol -DM -HTN -Smoking -Family history of premature CAD Emerging risk factors: -Lp(a) -Fibrinogen -Homocysteine -Urine microalbuminuria -Hs CRP -Markers of subclinical ASCVD ABI Carotid IMT 5/24/2021 3 MEU_IGMC&RI_ITP
- 5. IHD – Clinical Spectrum Acute • Unstable Angina • Acute Myocardial Infarction (NSTEMI, STEMI) • Prinzmetal Angina • Sudden Cardiac Death Chronic • Stable Angina • Microvascular Angina (Syndrome X) • Silent Ischemia 5/24/2021 5 MEU_IGMC&RI_ITP
- 6. • Remarks on Angina Pectoris” by John Warren, M.D., appeared in 1812 • Warren’s description of angina pectoris (derived from the Latin angina, “infection of the throat”; from the Greek ά́γχο′νη, “strangling”; and from the Latin pectus, “chest”) 5/24/2021 6 MEU_IGMC&RI_ITP
- 7. Angina Pectoris Retrosternal chest pressure, burning, or heaviness Radiating to neck, jaw, epigastrium, shoulders,along the ulnar surface of the left arm; the right arm and the outer surfaces of both arms may also be involved Precipitated by exercise, cold weather,emotional stress Begins gradually and reaches its maximum intensity over a period of minutes Duration 2-10 min.Relieved within minutes by rest or the use of nitroglycerin 5/24/2021 7 MEU_IGMC&RI_ITP
- 10. Unstable angina more severe Typically <20 min,present even at rest;crescendo pattern Acute myocardial infarction more severe Sudden onset, usually lasting ≥30 min; often associated with shortness of breath, weakness, nausea, vomiting Variant Angina occurs at rest but not with exertion - focal spasm of an epicardial coronary artery Levines Sign 5/24/2021 10 MEU_IGMC&RI_ITP
- 11. Anginal equivalents (i.e., symptoms of myocardial ischemia other than angina) - dyspnea, faintness,fatigue,eructations particularly in older patients and diabetics Nausea,vomiting,diarrhea,epigastric pain seen in IWMI Silent MI 5/24/2021 11 MEU_IGMC&RI_ITP
- 12. Clinical Classification of Chest Pain Typical angina (definite) Typical angina (definite) Substernal chest discomfort: characteristic quality, duration Provoked by stress Relieved by rest or nitroglycerin Atypical angina (probable) Meets 2 of the above characteristics Noncardiac chest pain Meets ≤1 of typical angina characteristics 5/24/2021 12 MEU_IGMC&RI_ITP
- 14. Acute Coronary Syndrome 5/24/2021 14 MEU_IGMC&RI_ITP
- 15. Definition of MI Detection of a rise and/or fall of cardiac biomarker values with at least one value above the 99th percentile (URL) and with at least one of the following: Symptoms of ischaemia New or presumed new significant ST-segment–T wave (ST–T) changes or new left bundle branch block (LBBB) Development of pathological Q waves in the ECG Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of an intracoronary thrombus by angiography or autopsy 5/24/2021 15 MEU_IGMC&RI_ITP
- 16. Examination • Signs of sympathetic activation: pallor, sweating, tachycardia • Signs of vagal activation: vomiting, bradycardia • Signs of impaired myocardial function Hypotension, oliguria, cold peripheries Narrow pulse pressure Raised JVP Third heart sound Systolic murmurs,pericardial rub Lung crepitations • Signs of tissue damage: fever 5/24/2021 16 MEU_IGMC&RI_ITP
- 17. ECG Initial ECG may be normal or nondiagnostic in one-third of cases Repeated ECG’s are important, especially where the diagnosis is uncertain or patient has recurrent or persistent symptoms Difficult to interpret if there is bundle branch block or previous MI 5/24/2021 17 MEU_IGMC&RI_ITP
- 18. STEMI ST elevation • New ST elevation at the J point in two contiguous leads with the following cut points: ≥0.1 mV in all leads (except V2-V3) In leads V2-V3 the following cut points apply: • ≥0.2 mV in men ≥40 years • ≥0.25 mV in men <40 years • ≥0.15 mV in women Sequential features are reliable for the approximate age of the infarct to be deduced 5/24/2021 18 MEU_IGMC&RI_ITP
- 23. CAUSES OF ST ELEVATION Ischemia/myocardial infarction Noninfarction, transmural ischemia (Prinzmetal's angina, and possibly tako-tsubo syndrome) Acute myocardial infarction Postmyocardial infarction (ventricular aneurysm pattern) Acute pericarditis Normal variant ("early repolarization" pattern) Left ventricular hypertrophy/left bundle branch block Other (rarer) Brugada pattern (right bundle branch block-like pattern with ST elevations in right precordial leads) Class 1C antiarrhythmic drugs DC cardioversion Hypercalcemia Hyperkalemia Hypothermia (J wave/Osborn waves) Myocardial injury Myocarditis Tumor invading left ventricle Trauma to ventricles
- 24. NSTEMI/Unstable Angina ST Depression and T Wave Changes • New horizontal or downsloping ST depression ≥0.05 mV in two contiguous leads • T-wave inversion ≥0.1 mV in two contiguous leads 5/24/2021 24 MEU_IGMC&RI_ITP
- 26. Plasma cardiac biomarkers MI causes a rise in the plasma concentration of enzymes and proteins that are normally concentrated within cardiac cells Biochemical markers: Creatine kinase (CK) Cardio-specific isoform (CK-MB) Cardio-specific proteins, Troponins T and I Serial estimations are helpful because it is the change in plasma concentrations of markers that confirms the diagnosis of MI Unstable angina - no detectable rise in cardiac biomarkers or enzymes 5/24/2021 26 MEU_IGMC&RI_ITP
- 28. Chest X-ray • Demonstrate pulmonary oedema that is not evident on clinical examination • Heart size is often normal Echocardiography • Useful for assessing ventricular function • Detecting important complications such as mural thrombus,cardiac rupture, VSD, mitral regurgitation and pericardial effusion 5/24/2021 28 MEU_IGMC&RI_ITP
- 29. Goals Of Immediate Management Identify candidates for reperfusion therapy Relief of ischemic pain as well as recognition and treatment of hypotension, pulmonary edema, and arrhythmia 5/24/2021 29 MEU_IGMC&RI_ITP
- 30. Treatment ▫ Supplemental oxygen should be administered if saturation is <90% ▫ Serial ECGs should be obtained for patients who do not have ST segment elevation on the initial ECG 5/24/2021 30 MEU_IGMC&RI_ITP
- 31. Analgesia To relieve distress To lower adrenergic drive and thereby reduce vascular resistance, BP, infarct size and susceptibility to ventricular arrhythmias Intravenous opiates (initially, morphine sulphate 5– 10 mg or diamorphine 2.5–5 mg) and antiemetics should be administered 5/24/2021 31 MEU_IGMC&RI_ITP
- 32. Antiplatelet therapy and Statins • ASA effectively blocks platelet aggregation within minutes and should be administered immediately Aspirin (ASA) 162-325 mg Nonenteric coated formulations (chewed or crushed) given orally or rectally facilitate rapid drug absorption and platelet inhibition. Clopidogrel 300-600 mg loading dose, 75-150 mg daily 600 mg loading dose followed by 7 d of 150 mg maintenance dose may reduce the incidence of stent thrombosis and MI Prasugrel 60 mg loading dose 10 mg daily quicker acting and more potent antiplatelet agent with improved efficacy should not be used in patients greater than 75 yr old, less than 60 kg, or with a history of stroke/TIA 5/24/2021 32 MEU_IGMC&RI_ITP
- 33. Statins • Loading dose of Statin – Atorvastatin 80 mg/Rosuvastatin 20-40 mg 5/24/2021 MEU_IGMC&RI_ITP 33
- 34. Antianginal Sublingual glyceryl trinitrate (300–500 μg) is a valuable first-aid measure in unstable angina or myocardial infarction Intravenous nitrates (glyceryl trinitrate 0.6–1.2 mg/hr or isosorbide dinitrate 1–2 mg/hr) are useful for the treatment of left ventricular failure and the relief of recurrent or persistent ischaemic pain Intravenous β-blockers (metoprolol 5–15 mg given over 5 mins) relieve pain,reduce arrhythmias 5/24/2021 34 MEU_IGMC&RI_ITP
- 35. Reperfusion Therapy All patients who present with a STEMI within 12 to 24 hours of symptom onset should be considered for immediate reperfusion therapy Choice of reperfusion strategy includes Thrombolysis Primary PCI Emergent CABG NSTEMI patients - Immediate emergency reperfusion therapy has no demonstrable benefit and thrombolytic therapy may be harmful 5/24/2021 35 MEU_IGMC&RI_ITP
- 36. • Door to needle time- 30 min (for patients receiving thrombolytic therapy) • Door to balloon time-90 min (for patients undergoing primary angioplasty) 5/24/2021 36 MEU_IGMC&RI_ITP
- 37. Primary Percutaneous Coronary Intervention (PCI) Treatment of choice for STEMI Outcome is best when it is used in combination with glycoprotein iib/iiia receptor antagonists and intracoronary stent Greater reduction in the risk of death, recurrent MI or stroke Primary PCI has been limited by availability of the necessary resources 5/24/2021 37 MEU_IGMC&RI_ITP
- 38. PCI is preferred over thrombolysis in patients who: • Presented within 12 hours of symptom onset and anticipated time from first medical contact to balloon inflation of 2 hours or less • Contraindications to fibrinolytic therapy • Presenting 12-24 hours of symptom onset with ongoing symptoms/signs of ischemia or hemodynamic instability • Presenting with cardiogenic shock • Underwent recent PCI or prior CABG 5/24/2021 38 MEU_IGMC&RI_ITP
- 40. Absolute Contraindications Relative Contraindications •History of intracranial hemorrhage or hemorrhagic stroke •Prior ischemic stroke more than 3 mo ago •Ischemic stroke within 3 mo •Allergy or previous use of streptokinase (greater than 5 d ago) •Known structural cerebrovascular lesion (AVMs, aneurysms, tumor) •Closed head injury within 3 mo •Recent internal bleeding (2-4 wk) •Aortic dissection •Prolonged/traumatic CPR more than 10 min •Severe uncontrolled hypertension (SBP > 180 mm Hg, DBP > 110 mm Hg) •Major surgery within 3 wk •Active peptic ulcer disease •Active bleeding or bleeding diathesis •Noncompressible vascular punctures •Severe menstrual bleeding •History of intraocular bleeding •Pregnancy 5/24/2021 40 MEU_IGMC&RI_ITP
- 41. Medication Dosage Comments Streptokinase (SK) 1.5 million units IV over 60 min Produces a generalized fibrinolytic state (not clot specific) Allergic reactions including skin rashes, fever, and anaphylaxis may be seen in 1-2% of patients Because of the development of antibodies, patients who were previously treated with streptokinase should be given an alternate thrombolytic agent 5/24/2021 41 MEU_IGMC&RI_ITP
- 42. BOLUS FIBRINOLYTICS Recombinant tissue plasminogen activator (rt- PA) 15 mg IV bolus 0.75 mg/kg over 30 min (maximum 50 mg) 0.50 mg/kg over 60 min (maximum 35 mg) Fibrin selective agent with improved clot specificity compared to SK. Does not cause allergic reactions or hypotension. Reteplase (r-PA) Two 10-unit IV boluses administered 30 min apart Fibrin selective agent with a longer half-life but reduced clot specificity compared to rt-PA. Tenecteplase (TNK-tPA) 0.50 mg/kg IV bolus (total dose 30-50 mg) Genetically engineered variant of rt-PA with slower plasma clearance, improved fibrin specificity, and higher resistance to plasminogen activator inhibitor-1 (PAI-1). 5/24/2021 42 MEU_IGMC&RI_ITP
- 44. Anticoagulants Reduces the risk of thromboembolic complications and prevents re-infarction in the absence of reperfusion therapy or after successful thrombolysis Should be continued for 8 days or until discharge from hospital or coronary revascularisation 5/24/2021 44 MEU_IGMC&RI_ITP
- 45. Unfractionated heparin (UFH) 60 units/kg IV bolus, 12 units/kg/hr UFH should be given to all patients undergoing PCI and those receiving thrombolytics Enoxaparin (LMWH) 30 mg IV bolus, 1 mg/kg SC bid Patients greater than 75 yr of age should not be given a loading dose and receive 0.75 mg SC bid. Bivalirudin 0.75 mg/kg IV bolus, 1.75 mg/kg/hr Bivalirudin has been validated in patients undergoing PCI Fondaparinux 2.5 mg IV bolus, 2.5 mg SC daily Shown to be superior to UFH when used during thrombolysis with decreased bleeding rates. 5/24/2021 45 MEU_IGMC&RI_ITP
- 49. Indications for PCI in NSTEMI • Refractory angina • Recurrent angina • Clinical symptoms of heart failure or hemodynamic instability • Life-threatening arrhythmias (ventricular fibrillation or ventricular tachycardia) 5/24/2021 49 MEU_IGMC&RI_ITP
- 52. Mechanical: Ventricular septal defect: - Seen 2 to 5 day after MI - common in older females,Hypertension,Anterior infarction Papillary muscle rupture: - Common in inferiorwall MI - Sudden onset pulmonary edema and cardiogenic shock 5/24/2021 52 MEU_IGMC&RI_ITP
- 54. Cardiac Rupture: - Occurs within 2 weeks - After transmural MI - Electromechanical dissociation and sudden death 5/24/2021 54 MEU_IGMC&RI_ITP
- 55. Ventricular Aneurysm: - Transmural anteroseptal infarct - Persistent ST segment elevation > 6 weeks 5/24/2021 55 MEU_IGMC&RI_ITP
- 56. Cardiogenic Shock: - Females,diabetics,AWMI,prior MI,old age - Atleast 40% of Lt Ventricle should be affected Causes: -Extensive LV infarction -Extensive RV infarction -VSD,Acute MR -Cardiac tamponade with free wall rupture 5/24/2021 56 MEU_IGMC&RI_ITP
- 57. RV Failure: - After IWMI -Hypotension,JVD,absence of dyspnea -Fluid administration -Nitrates should be avoided 5/24/2021 57 MEU_IGMC&RI_ITP
- 58. Arrhythmias Electrical instability Pump failure, excessive sympathetic stimulation Bradyarrhythmias and conduction disturbances Ventricular premature beats Sinus tachycardia Sinus bradycardia Ventricular tachycardia Atrial fibrillation and/or atrial flutter Junctional escape rhythm Ventricular fibrillation Paroxysmal supraventricular tachycardia Atrioventricular block and intraventricular block Accelerated idioventricular rhythm Nonparoxysmal atrioventricular junctional tachycardia 5/24/2021 58 MEU_IGMC&RI_ITP
- 59. 5/24/2021 MEU_IGMC&RI_ITP 59 AIVR is particularly common with acute MI Sign of reperfusion after the use of thrombolytic agents or after interventional coronary artery procedures Short lived, lasting minutes or less, and usually requires no specific therapy
- 60. Ischemic Infarct expansion Post infarct angina (few hrs to 30 days after Acute MI) Embolic Complications Pericarditis Early- After Transmural MI Late- Dresslers Syndrome - 1 to 8 weeks after MI,due to autoimmune mechanism 5/24/2021 60 MEU_IGMC&RI_ITP
- 63. Lifestyle modification • Diet (weight control,lipid-lowering,‘Mediterranean diet’) • Cessation of smoking • Regular exercise 5/24/2021 63 MEU_IGMC&RI_ITP
- 64. • Aspirin is the preferred antiplatelet agent after MI and should be used indefinitely • Doses of 75 to 325 mg/d have been shown to reduce the risk of recurrent MI, stroke, and cardiac death • Clopidogrel (75 mg/d) or Prasugrel (10 mg/d) should be given for a minimum of 1 month in patients who receive a BMS and for at least 1 year in patients who receive a DES 5/24/2021 64 MEU_IGMC&RI_ITP
- 65. β-Blockers confer a mortality benefit following acute MI. Treatment should begin as soon as possible (preferably within the first 24 hours) and continued indefinitely ACE inhibitors provide a reduction in short-term mortality and incidence of CHF and recurrent MI when initiated within the first 24 hours of an acute MI 5/24/2021 65 MEU_IGMC&RI_ITP
- 66. HMG-CoA reductase inhibitors should be started in all patients in the absence of contraindications. The goal is at least 50% reduction in LDL or LDL less than 70 mg/dL Aldosterone receptor antagonists have shown benefit in post-MI patients with LV ejection fraction of less than 40% Therapy for control of diabetes and hypertension 5/24/2021 66 MEU_IGMC&RI_ITP
- 68. • Resting ECG • Exercise ECG • Stress Echocardiography • Myocardial perfusion scanning • CT Angiography • Coronary arteriography 5/24/2021 MEU_IGMC&RI_ITP 68
- 71. T-wave flattening or inversion in some leads, providing non-specific evidence of myocardial ischaemia or damage Evidence of previous MI Normal even in patients with severe CAD 5/24/2021 71 MEU_IGMC&RI_ITP
- 72. Exercise ECG Assessing the severity of coronary disease and identifying high-risk individuals Performed using a standard treadmill or bicycle ergometer protocol Monitoring the patient’s ECG, BP and general condition Planar or down-sloping ST segment depression of 1 mm or more is indicative of ischaemia 5/24/2021 72 MEU_IGMC&RI_ITP
- 74. Stress Echocardiography • Uses transthoracic echocardiography • Identify ischaemic segments of myocardium and areas of infarction 5/24/2021 74 MEU_IGMC&RI_ITP
- 75. Myocardial perfusion scanning • Evaluation of patients with an equivocal or uninterpretable exercise test and those who are unable to exercise • Scintiscans of the myocardium at rest and during stress • 201 Thallium • 99mTc-MIBI • 99mTc-Tetrofosmin • 99mTc-Teboroxime • Perfusion defect present during stress but not at rest provides evidence of reversible myocardial ischaemia • Persistent perfusion defect seen during both phases of the study is usually indicative of previous MI 5/24/2021 75 MEU_IGMC&RI_ITP
- 77. CT Angiography ▫ Noninvasive approach to imaging atherosclerosis and its consequences ▫ Detecting coronary calcification, which is a good marker of the total coronary atherosclerotic burden ▫ Angiography of the coronary arterial tree, assessment of myocardial perfusion and quantification of ventricular function 5/24/2021 77 MEU_IGMC&RI_ITP
- 79. Coronary arteriography • Detailed anatomical information about the extent and nature of coronary artery disease • Performed with a view to coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) 5/24/2021 79 MEU_IGMC&RI_ITP
- 83. Treatment of Stable Angina 5/24/2021 83 MEU_IGMC&RI_ITP
- 85. Anti-anginal • Help to relieve or prevent the symptoms of angina Nitrates Β-blockers Calcium antagonists Potassium channel activators If channel antagonist Ranolazine 5/24/2021 85 MEU_IGMC&RI_ITP
- 87. Antiplatelet therapy ASPIRIN (75 mg) • Reduces the risk of MI • Prescribed for all patients with CAD indefinitely CLOPIDOGREL (75 mg daily) • Prescribed if aspirin causes troublesome dyspepsia or other side-effects 5/24/2021 87 MEU_IGMC&RI_ITP
- 88. Percutaneous coronary intervention (PCI) is performed by passing a fine guidewire across a coronary stenosis under radiographic control and using it to position a balloon, which is then inflated to dilate the stenosis (Ballon Angioplasty ) A coronary stent is a piece of coated metallic‘scaffolding’ that can be deployed on a balloon and used to maximise and maintain dilatation of a stenosed vessel Mainly used in single- or two-vessel disease 5/24/2021 88 MEU_IGMC&RI_ITP
- 92. 5/24/2021 92 MEU_IGMC&RI_ITP -Bare metal stent -Drug Eluting Stent
- 93. Acute complications: Occlusion of the target vessel or a side branch by thrombus Coronary artery dissection Long-term complications: Re-stenosis - due to a combination of elastic recoil and smooth muscle proliferation (neo- intimal hyperplasia) 5/24/2021 93 MEU_IGMC&RI_ITP
- 94. Coronary Artery Bypass Grafting Under cardiopulmonary bypass or ‘off-pump’ surgery Internal mammary arteries, radial arteries or reversed segments of the patient’s own saphenous vein used to bypass coronary artery stenosis INDICATED IN Three-vessel disease Two-vessel disease that includes the proximal LAD and impaired global LV function Diabetes mellitus Left main coronary artery disease 5/24/2021 94 MEU_IGMC&RI_ITP
- 99. Prinzmetal / Variant Angina • Younger and have fewer coronary risk factors • Detection of transient ST-segment elevation with rest pain • Coronary angiography demonstrates transient coronary spasm ,most common in the right coronary artery • Nitrates and calcium channel blockers are the main agents used to treat acute episodes and to abolish recurrent episodes of PVA 5/24/2021 99 MEU_IGMC&RI_ITP
- 101. 101 Pathophysiology: Dynamic small vessel constriction (vasospasm) (positive stress testing)
- 102. Summary A Aspirin and anti-anginals B Beta-blockers and blood pressure control C Cholesterol and cigarettes D Diet and diabetes E Education and exercise 5/24/2021 102 MEU_IGMC&RI_ITP