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Punit Goel, MD
Asst Professor in Cardiology, University of
Missouri Hospital & Clinics
Staff Cardiologist, Harry Truman VA Hospital
Epidemiology
Risk factors
Pathogenesis
Spectrum
Prevention
Coronary vasculature
angina, MI, sudde
Cerebral
TIA, stroke
Peripheral
claudication, gangrene
Renal
hypertension
Epidemiology
Risk factors
Pathogenesis
Spectrum
Prevention
Epidemiology
Disease impact:
Economic impact:
Epidemiology
Risk factors
Pathogenesis
Spectrum
Prevention
-Age
-Male gender
-Dyslipidemia
High LDL cholesterol
Low HDL cholesterol
-DM
-HTN
-Smoking
-Family history of premature CAD in first degr
Dyslipidemia
40
(De aths/100 0)
50
30
20
10
150
200
250
300
150
125
100
75
50
25
0
204
205-234
235-264
265-294
295
Hypertension
Smoking
Obesity
It contributes independently to CVD risk and
also aggravates
known
CVD risk
factors.
Measures of obesity include:
BMI
Waist: hip ratio.
Diabetes Mellitus
Patients with either type I or type II diabetes
have increased
risk for CVD
Risk of CHD is increased 2-fold in young men
and 3-fold in
young women with type 2 diabetes
Type II diabetics have one or more metabolic
abnormalities
(hypertriglyceridemia, low HDL,
hypertension)
(Circulation 1998;97:18
Metabolic syndrome:
-Abdominal obesity: waist circumference
Men >40 inches
Women >35 inches
-Triglycerides >150 mg/dl
-HDL
Men <40 mg/dl
Women <50 mg/dl
-BP >130/85 mm Hg
-Fasting glucose >100 mg/dl
(presence of 3 or more criteria constitutes metabolic syndrome)
Epidemiology
Risk factors
Pathogenesis
Spectrum
Prevention
Pathogenesis
Endothelium:
Initiation of atherosclerosis
Lipoprotien accumulation and modification
fatty streak formation
lipid oxidation
nonenzymatic glycation
LDL
Binds to receptor on endothelial cell surface
Internalized
Oxidized to oxidized-LDL
Ingested by
Macrophages
Foam Cell
Increased adherence
and migration of T-cells,
monocytes from the lumen
into the wall
Vulnerable plaques
Thin fibrous cap
Large lipid core
High macrophage content
Stable plaques
Thick cap
Dense extracellular matrix
Less lipid rich core
Epidemiology
Risk factors
Pathogenesis
Spectrum
Prevention
10/00
medslides.com
Improvement in Mortality
30-DayMortality(%)
35
30
25
20
15
10
5
0
30%
Bed
rest
13%-15%
Defibrillation
Defibrillation
Hemodyna
Hemodynamic
mic
monitoring
monitoring
-Block
-Blockade
ade
Pre-CCU Era
CCU Era
5.0%- 6.5%
Aspirin,
Aspirin, PTCA,
PTCA,
Lysis
Lysis
Reperfusion Era
Pathophysiology
Spectrum
Spectrum of
of Acute
Acute Coronary
Coronary Syndromes:
Syndromes: Hematologic
Hematologic
Findings
Findings in
in Q-Wave
Q-Wave AMI
AMI
Stable angina Unstable NonQ-wave Q-wave
angina
AMI
AMI
Angiographic thrombus
0%-1%
75%
>90%
Increased FPA/TAT
0%-5%
60%-80%
80%-90%
Activated platelets
0%-5%
70%-80%
80%-90%
0%-1%
10%-25%
>90%
Mortality
1%-2%
3%-8%
6%-15%
Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine, 5th ed. Philadelphia, Pa: WB Saunders; 1997.
Presentation:
Atypical presentations:
confusion, syncope, profound wkness, arrhy
Differential diagnosis:
Pericarditis
Pulmonary embolism
Pneumothorax
Aortic dissection
Esophageal spasm
Examination:
Laboratory findings:
Cardiac imaging
2D echocardiography
reveals regional wall motion abnormality
also useful to identify mechanical complicatio
of MI
Radionuclide imaging
used infrequently in the diagnosis of acute MI
mainly used to risk stratify patients with CHD
Management
Prehospital care:
STEMI
ASA, beta blockers, antithrombin therapy
<12 hrs
Eligible for
Lytic therapy
Thrombolysis
>12 hrs
Lytic C/I
Not a candidate
For reperfusion
Primary PCI
Persistent
symptoms
no
yes
Consider reperfusion
Time is muscle
Reimer/Jennings1977
Bergmann1982
GISSI-I 1986
100
%Benefit
80
60
40
20
0
4
6
8
ReperfusionTime(hours)
Ada pte d from Tiefenbrunn AJ, Sobel BE . Circu latio n. 1992 ;85 :231 1-2315 .
10
12
30-Day Mortality ( %)
Importance
Importance of
of Time-to-Treatment:
Time-to-Treatment: Results
Results of
of GUSTO-I
GUSTO-I
12
10
8
6
4
2
0
2=149 (1 df )
9 10 11 12
TimeFromOnsetofSymptomstoTreatment(hours)
The
The Four
Four Ds
Ds
ED Time Point 4:
DRUG
ED Time Point
Point 3:
3:
DECISION
ED Time Point 2:
2:
DATA
ED Time Point 1:
DOOR
Time Interval II
ECG to decision to treat
Time Interval I
Door to ECG
Time of Onset
NHAAP Reco mmend atio ns. U.S. Depa rtment of Health NIH Pub lication : 1997:97-3 787.
Unstable angina/NSTEMI
Aspirin, antithrombin, nitrates, GP
IIb-IIIa antagonist
Betablockers(calcium channel
blockers)
Assess clinical status
High risk/unstable
(Recurrent ischemia, LV dysfunction
Widespread EKG changes, positive
enzyme markers)
Cardiac catheterization
yes
Revascularization (PCI/CABG)
Stable
Stress test
Severe ischemia
no
Medical therapy
Epidemiology
Risk factors
Pathogenesis
Spectrum
Prevention
Prevention:
Dyslipidemia:
It is the most established and best
understood risk
factor for
atherosclerosis. National guidelines
recommend cholesterol screening with
fasting
lipid profile in all adults.
Individuals with dyslipidemia should have
dietary
modification
Normal total cholesterol should not
reassure individuals
having other risk factors or low HDL
Primary and secondary prevention trials
in individuals with not only high but
Circulation 2004;110:227-23
Diabetes mellitus:
Diabetic dyslipidemia is characterized by:
normal LDL- but more dense and atherogenic
low HDL
elevated triglycerides
Hypertension:
Smoking cessation: