CAD - Ischemic Heart Disease

Atherosclerosis
Definition: focal disease of the inner layer of large and medium-sized arteries.
Single most common “killer”
In 2008 17,3 million deaths (7,3 MI, 6,2 stroke)
About ½ of deaths in developed countries
Involves many vascular beds and thus causes various diseases

Clinical Presentation?

Risk factors of atherosclerosis

Atherosclerosis is a systemic disease but can be prevented —> Primary prevention is a key approach.

Non modifiable
Age Gender Genetic
Modifiable
Hyperlipidemia Arterial hypertension Diabetes mellitus
Smoking Physical inactivity Obesity

Dyslipidemia: prevalence & mortaility of CVD positively correlates w/ the lv of total cholesterol & LDL
Tx:
 diet, exercise, avoid secondary behavioral
 statins, ezetimibe, fibrate, PCSK9

Smoking:
- active & passive smoking is a very important risk-factor
nicotine promote LCL-C oxidization  endothelial dysfunction  prothrombogenic + promote insulin resistence
- smoking cessation is the most effective mean of CV dz prevention & may lead to 36% reduction of MI mortality

Obesity:
Adult- normal BMI 18.5-24.9. - overweight 25-29.9 - obesity >30 extreme obesity >40
2-19: 85th percentile 95th per.  120% of 95th percentile
ANA BP categories:
Normal: <120/80 HTN stage 1: 130-139/80-89 HTN crisis:  180/120
Elevated: 120-129/80 HTN stage 2:  140/90

Stable Ischemic Heart Disease

- Characterized by transient myocardial ischemia
- Most commonly caused by obstruction of the coronary arteries by atheromatous plaque

Physiology of coronary circulation

- Coronary blood flow is phasic with maximal flow in diastole.
- 75% of the oxygen delivered by coronary arteries is extracted by LV → limited oxygen extraction reserve in
coronary circulation.
- At 85% lumen diameter reduction at rest (85% at maximum exercise), vasodilator reserve is exhausted →
inadequate pressure distal to the stenosis → rest or exertional myocardial ischemia
Classification
- Chronic stable angina pectoris:
 Typical angina pectoris &/or other symptoms:

- Variant angina pectoris:

 Angina at rest associated with transient ST-segment elevation, both resolving with the administration of nitrate.
- Microvascular AP and syndrome X:
 AP caused by coronary microvascular dysfunction in pts who have nonstenotic arteries on coronary angiography

- Asymptomatic myocardial ischemia

 The objective evidence of myocardial ischemia (ECG) in the absence of chest pain.

Classification of CP:
Typical angina:
1. substernal chest discomfort w/ characteristic quality & duration
2. Provoked by exertion or emotional stress
3. Relieved by rest ot NGT
Atypical angina: meets 2 of the above characteristics
Noncardiac CP: meets 1 or none of the typical characteristics

Grading of angina
pectoris
Evaluation
History- typical symptoms
Laboratory evaluation
dyslipidemia, hyperglycemia, renal disease etc.
biomarkers- hs-CRP, MMP-1, PAPP-A
Resting ecg Stress testing Coronarography
ECHO CT angio

Biochemistry: total cholesterol, LDL, HDL, TAG, hs-CRP, hs-Tnl, fasting plasma glucose level, HBA1C

Echocardiography:
Evaluation of LV function, localized kinetic defect
Evaluation of other disease causing angina pectoris (AS, HKMP).
LV function= strongest predictor of long-term survival
A patient with an LVEF <50% is already at high risk for CV death
Stress tests: (dobutamine stress test)
Exercise/pharmacological myocardial perfusion imaging using single photon emission tomography (SPECT)

Coronary CTA
+
 shows anatomical detail as well as the burden of CAD
 has reasonable sensitivity and specificity in detecting severe CAD as well as an excellent negative
predictive value in excluding significant CAD
-
 lower positive predictive value
 greater radiation doses to the patient compared to invasive coronary angiograph
 does not give valid information about the functional significance of coronary atherosclerotic lesions

Selective invasive coronary angiography

 the gold standard in assessing the severity of CAD
 excellent reliability in assessing severe and mild disease
 determine the functional significance of any given coronary stenosis with measurement of fractional
flow reserve (FFR)
 Intravascular ultrasound (IVUS) can also be used at the time of coronary angiography to assess plaque
morphology and vessel size in order to guide decisions regarding the approach to PCI or whether a
patient may be better served with medical therapy or CABG.

Management
 Optimal medical therapy:
 symptom relieving drugs: anti-ischemic drug
 nitrates: coronary arteriolar and venous vasodilatation
- Short-acting nitrates for acute effort angina (sublingual nitroglycerin)
- Long-acting nitrates for angina prophylaxis (Isosorbide dinitrate, Mononitrates)
 Betablockers: reduce heart rate, contractility, AV conduction, increase perfusion of ischemic areas
by prolonging the diastole (metoprolol, bisoprolol, atenolol)
 Calcium channel blockers: vasodilation and reduction of the peripheral vascular resistance
- Non-dihydropyridines e.g.heart rate-lowering (Verapamil, Diltiazem)
- Dihydropyridines (amlodipin)
Event prevention
 Antiplatelet agents:
- decrease platelet aggregation and may prevent formation of coronary thrombus (low dose ASA, Plavix)
 Lipid-lowering agents:
- (treatment target is LDL-C < 1.8 mmol/L)
 Renin-angiotensin-aldosterone system blockers: reduce total mortality, MI, stroke and heart failure
among specific subgroups of patients (HF, PAD, DM)

 Ravascularization: OCI, CABG

Revascularization therapy: Coronary artery bypass graft (CABG), Percutaneous coronary intervention (PCI)
Angina despite medical therapy?
Significant ischemia?
More than 10% on SPECT
More than 3 segments on stress ECHO
FFR <0.80
Systolic dysfuntion?
Coronary anatomy: Multivessel disease, left main disease, proximal LAD