Enfermedad coronaria

Carolina Valdebenito Torres

Universidad Santo Toms

Los ngeles

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Ateroesclerosis
Se inicia en la infancia y progresa con los aos
Se caracteriza por engrosamiento fibrosos relacionados con
placas lipdicas infiltrantes
Placas antiguas son proclives a la ulceracin y la rotura
El 28,5% de la mortalidad es producto de trastornos
circulatorios

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Ateroesclerosis
La clula puede producir un 50% del colesterol
aproximadamente y el resto se aporta de la dieta
Funciones de los lpidos:
Forman parte de membranas celulares
Constituyen hormonas esteroidales
Permitan almacenar energa

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Ateroesclerosis
Patogenia de las dislipidemias:
Primarias:
Factores genticos
Secundarias:
Factores exgenos:
Dieta inadecuada
Sedentarismo
Factores endgenos:
Diabetes mellitus
Hipotiroidismo

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Ateroesclerosis
Sndrome dismetablico cardiovascular:
Dislipidemias
Resistencia insulnica
Obesidad
Hipertensin arterial

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Ateroesclerosis
Complicaciones:
Insuficiencia vascular de las extremidades
Anormalidades de la circulacin renal
Dilataciones (aneurismas) con rotura aortica y otras
arterias
Enfermedad cardiaca
Enfermedad enceflica

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Patogenia
Lesin endotelial
por fuerzas de
friccin

Infiltracin de LDL
en la regin
subendotelial

Estimulacin de la
liberacin de citocinas
Inhibicin de la
produccin de NO
Estimulan clulas del
musculo liso vascular
Atraen macrfagos

LDL oxidadas
Capturadas por
macrfagos

Atraen clulas T
y macrfagos

Lesin
ateroesclertica

Clulas
espumosas

Estras adiposas

Estimulan migracin
clulas musculo liso
vascular

Proliferan,
expresan
colgena
Contribuyen al
cuerpo de la
lesin

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Patogenia

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Patogenia
Las fuerzas de friccin tienden a provocarse en
zonas de fuerza intensa como son los puntos de
ramificacin
Las estras aparecen:
Aorta: primeros 10 aos de vida
Coronarias: segundo decenio
Cerebrales: tercer u cuarto decenio
Conforme las placas maduran se forma un tejido
fibroso sobre ellas

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Patogenia

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Manifestaciones clnicas
Angina de pecho (lumen disminuido >75%)
Infarto agudo del miocardio
Enfermedad vascular cerebral trombtica
Hipertensin renovascular
Claudicacin intermitente
Gangrena

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Factores de riesgo
Sexo masculino y mujeres postmenopusicas
Antecedentes familiares
Hiperlipemia primaria
Hiperlipemia secundaria
Tabaquismo
Hipertensin arterial
Diabetes mellitus
Obesidad
Sndrome nefrtico
Hipotiroidismo (disminucin de receptores de LDL hepticos)
Aumento de lipoprotenas
Homocisteina

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Clnica:

Dolor torcico sordo con irradiacin del brazo o mandbula

No empeora con respiracin profunda
Se acompaa de diaforesis, nauseas y vmitos
Ex fsico:
Cuarto ruido cardiaco
Insuficiencia cardiaca congestiva
Choque

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Etiologa:
Obstruccin trombtica de los grandes vasos epicrdicos
Espasmos de las arterias coronarias (serotonina e histamina)
Anormalidades congnitas (raras)

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Fisiopatologa.
El corazn es responsable del 70% del consumo de oxigeno corporal en
reposo
Isquemia:
Demanda de oxigeno se incrementa con respecto al suministro arterial mximo:
Tirotoxicosis
Estenosis aortica

Disminucin absoluta del suministro arterial de oxigeno:

Enfermedad ateroesclertica
Intoxicacin por monxido de carbono
Anemia

El consumo de cocana puede incrementar la demanda de oxigeno y producir

vasoespasmo disminuyendo el suministro.

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Placa ateroma

Flujo turbulento
sangre
Estrs
chorro

Rotura de placa

Exponer
colgeno

Activacin de
plaquetas

Disfuncin endotelio

Disminucin
vasodilatacin
natural

Liberacin
tromboxano
Vasoconstriccin
Formacin de trombo

Diminucin de
sustancias
antitrombina

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Obstruccin
arteria coronaria

60 s

Disfuncin en
la relajacin y
contraccin
miocrdica

Infarto

Muerte
celular

Deplecin
glucgeno

Tensin de
oxigeno
miocrdico
baja a 0

Tumefaccin
miocrdica
difusa

Lesin
membrana
celular

Mantiene
obstruccin por 4060 minutos

Disminucin
rpida de los
almacenes de
fosfato cardaco
Metabolismo
anaerobio

Produccin
de acido
lctico

Restablece
flujo

Angina

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Clasificacin:
Angina estable:
Solo en el ejercicio
Estabilidad en el tiempo
Angina inestable:
Dolor en reposo
Infarto agudo al miocardio:
Dolor torcico prolongado sin interrupcin, asociado a
lesin miocrdica
Muerte sbita:
Puede obedecer a mltiples causas
Generalmente se asocia a aparicin de arritmias graves
(FV)

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Manifestacin clnicas:
Dolor torcico:
Mediada por fibras simpticas aferentes
Viajan de regreso al ganglio simptico torcico superior
y las 5 races nerviosas dorsales posteriores de la
medula
El desencadenante es la adenosina
Isquemia silenciosa:
Disfuncin de los nervios aferentes
Disminucin transitoria de la perfusin
Diferencias en el umbral del dolor

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Manifestaciones clnicas:
Cuarto ruido cardiaco y respiracin entrecortada
Disfuncin diastlica y sistlica
Estado de choque
A mayor cantidad de miocardio suministrado por el
vaso ocluido, mayor intensidad e importancia de los
sntoma
Rotura de tabique interventricular, pared valvular o
miocrdica
Bradicardia
Infarto pared inferior

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Cardiopata coronaria
Manifestaciones clnicas:
Nauseas y vmitos
Activacin del nervio
vago en infarto pared
inferior
Taquicardia
Aumento de
catecolaminas para
mantener volumen

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________