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atherosclerosis
Atheroma
Artery wall
Blood within
the artery
Atheroma
(fatty deposits)
building up
Atheroma
atheroma
Atheroma (fatty layer)
Cross Section
Longitudinal Section
heart attack
due to sudden
blockage of the
coronary artery
chest pain like a
band, indigestion,
breathlessness,
sickness, looking pale
comes on at any time
doesnt go away - if still
there in 15 minutes call
999
Cardiac arrest
the heart stops beating when it quivers or fibrillates
causing the person to collapse
Stroke
an artery leading to the brain is suddenly blocked with
a blood clot or a bleed
smoking
inactivity
obesity and overweight
high blood pressure
raised blood cholesterol
diabetes
family history of coronary heart disease
excessive alcohol intake
ANGINA PECTORIS
Angina pectoris is a clinical syndrome
usually characterised by paroxysms of
pain or pressure of anterior lobe.the
cause is usually insufficient blood flow
TYPES
Stable angina
Predictable consistent pain that occurs in
exertion and is relieved by rest
Unstable angina
Also called preinfarction angina
Symptoms occur frequently and last longer than
stable angina
Pain may occur at rest
Variant angina
Also called prinzmentals angina.
Pain at rest with reversible ST segment
elevation thought to be caused by
coronary artery vasospasm
Microvascular angina
Patient have chest pain but do not seem
to have any blockage in coronary artery
The pain may be due to tiny vessels that
feed heart,arm and neck are not working
properly
Silent ischemia
Objective evidence of ischemia (such as
electrocardiographic changes with a stress
test) but patient report no symptoms
Stable CAD
Acute Coronary Syndromes
Unstable angina
Non-ST Elevation MI
(Non-Q-wave MI)
ST-Elevation MI
(Q-wave MI)
Vulnerable
Plaque
Plaque Rupture
Physical Stress
Emotional
Stress
Unstable Angina
Prior stable angina
in:
Frequency
Duration
Intensity
Symptoms
Pain
Sympathetic response
Parasympathetic response
Inflammatory response
Pressure
Burning (hot)
Chest/arms/jaw/back
Sweats
Tachycardia
Cool, clammy skin
Nausea
Vomiting
Weak
Mild fever
Other
Dyspnea
Asymptomatic
Physical Findings
Inspection
BP
HR
Diagnosis of ACS
Unstable Angina
Myocardial Infarction
NSTEMI
Typical symptoms
STEMI
Serum biomarkers
No
Yes
Yes
ST depression and/or
ST depression and/
ST elevation (and Q
T wave inversion
or T wave inversion
waves later)
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182
Serum Markers of
Myocardial Infarction
Myocardial necrosis causes sarcolemma
disruption
Intracellular macromolecules are released
Can be measured by serial blood testing
Pattern and level of rise correlates with
timing and size of MI
Cardiac-Specific Troponins
Regulatory protein that controls interaction
between actin & myosin
3 subunits: TnC, I, T
Skeletal &
cardiac muscle
Creatinine Kinase
Enzyme that converts ADP to ATP
Found in many tissues: heart, brain, skeletal
muscle, kidney, etc.
Can be elevated after injury to any of these
tissues
3 isoenzymes:
- CK-MM
- CK-MB
- CK-BB
CPK-MB
Makes up 1-3% of skeletal CK
Makes up much higher % of cardiac CK
Rises 4-8 hours after MI, peaks by 24 hours
Returns to normal in 48-72 hours
Treatment of Acute
Coronary Syndromes:
STE vs. Non STE
-blocker
Nitrates
+/- Calcium channel blocker
General measures:
Antithrombotic therapies
Antiplatelet agents:
Adjunctive therapies:
Aspirin
Clopidogrel (or prasugrel)
LMWH (enoxaparin)
Unfractionated intravenous heparin
Fondaparinux
Bivalirudin (should be used in ACS
patient only if undergoing PCI)
Statin
Angiotensin converting-enzyme inhibitor
Non-ST-Elevation
(UA and NSTEMI)
Risk Assessment
(e.g., GRACE Score)
No
Fibrinolytic
Therapy
(e.g., tPA)
Yes
Primary PCI
Low
Conservative
Strategy
(Proceed to cardiac cath
only if recurrent angina
or predischarge
stress test is markedly
positive)
High
Invasive
Strategy
(Cardiac cath
leading to
PCI or CABG)
Nitrates
Reduce ischemia (not mortality)
Venodilation:
R heart return
Coronary vasodilation
Usually given SL then IV
Beta Blockers
O2 demand
Shear stress
Non Dihydropyridine
Calcium Channel Blockers
Heart rate
Vasodilate
Relieve ischemia, not mortality
Dont give in patients with sx/signs
of heart failure
Early Invasive
Urgent catheterization performed after
initial medical Rx
Allows rapid identification & Rx of
critical CAD
More PCI/CABG
Aspirin
Reduces mortality & reinfarction
Give immediately on presentation
and daily thereafter
If aspirin allergy, use clopidogrel
Heparin
Give 1-2 days IV after PCI or lysis with tPA, rPA,
or TNK-tPA NOT SK
Also if:
Atrial fibrillation
LV thrombus
- Blockers
Nitrates
Reduce pain/ischemia
Relieve pain
Reduce pulmonary congestion in
heart failure
ACE - Inhibitors
Limit adverse LV remodeling
Heart failure/death
MI
Statins
Reduce reinfarction, death
More benefit when started early
Give if LDL cholesterol is > 100
Complications of MI
Myocardial Infarction
Ventricular
thrombus
Embolism
Contractility
Cardiogenic
shock
Ischemia
Electrical
instability
Arrhythmias
Tissue
necrosis
Pericardial
inflammation
Pericarditis
Hypotension
Coronary
perfusion
pressure
Cardiac
tamponade
Standard Discharge Rx