Coronary Artery Coronary Artery Disease and Acute Disease and Acute

Coronary Coronary SyndromeSyndrome

Coronary Artery Coronary Artery Disease and Acute Disease and Acute

Coronary Coronary SyndromeSyndrome

The Heart as a PumpThe Heart as a Pump

► The heart is a The heart is a hollow muscular hollow muscular organ about the organ about the same size as your same size as your fist.fist.

► It is a 2 sided pump, It is a 2 sided pump, with a muscular wall with a muscular wall called the septum called the septum separating the right separating the right and left sidesand left sides

The Coronary ArteriesThe Coronary Arteries

► As a muscle the heart As a muscle the heart needs oxygen and needs oxygen and nutrients to worknutrients to work

► The heart muscle has The heart muscle has its own blood supply its own blood supply through the coronary through the coronary arteriesarteries

► Women’s coronary Women’s coronary arteries tend to be arteries tend to be smallersmaller

DescriptionDescription

►Coronary Artery Disease (CAD)Coronary Artery Disease (CAD) A type of blood vessel disorder A type of blood vessel disorder

that is included in the general that is included in the general category of atherosclerosiscategory of atherosclerosis

DescriptionDescription

►AtherosclerosisAtherosclerosis Can occur in any artery in the bodyCan occur in any artery in the body Atheromas (fatty deposits)Atheromas (fatty deposits)

►Preference for the coronary Preference for the coronary arteriesarteries

DescriptionDescription

►AtherosclerosisAtherosclerosis Terms to describe the disease process:Terms to describe the disease process:

►Arteriosclerotic heart disease (ASHD)Arteriosclerotic heart disease (ASHD)►Cardiovascular heart disease (CHD)Cardiovascular heart disease (CHD)►Ischemic heart disease (IHD)Ischemic heart disease (IHD)►CADCAD

DescriptionDescription

►Cardiovascular diseases are the major Cardiovascular diseases are the major cause of death in the US and Canadacause of death in the US and Canada

►Heart attacks are still the leading Heart attacks are still the leading cause of all cardiovascular disease cause of all cardiovascular disease deaths and deaths in generaldeaths and deaths in general

Etiology and PathophysiologyEtiology and Pathophysiology

►Atherosclerosis is the major cause of Atherosclerosis is the major cause of CADCAD Characterized by a focal deposit of Characterized by a focal deposit of

cholesterol and lipids, primarily within the cholesterol and lipids, primarily within the intimal wall of the arteryintimal wall of the artery

Process of Coronary Artery Process of Coronary Artery Disease - AtherosclerosisDisease - Atherosclerosis

► Over time ….a series of Over time ….a series of events within the artery events within the artery A fatty streak A fatty streak

(permanent)– can start in (permanent)– can start in infancy & young childreninfancy & young children

Fatty – ( lipid) deposits Fatty – ( lipid) deposits throughout the yearsthroughout the years

Narrowing and impaired Narrowing and impaired blood flow occurs with blood flow occurs with the gradual occlusion as the gradual occlusion as plaque thickens and plaque thickens and blood clots formblood clots form

Etiology and PathophysiologyEtiology and Pathophysiology

►Endothelial lining altered as a result of Endothelial lining altered as a result of chemical injurieschemical injuries Hyperlipidemia Hyperlipidemia HypertensionHypertension

Etiology and PathophysiologyEtiology and Pathophysiology

►Bacteria and/or viruses may have role Bacteria and/or viruses may have role in damaging endothelium by causing in damaging endothelium by causing local inflammationlocal inflammation

►C-reactive protein (CRP)C-reactive protein (CRP) Nonspecific marker of inflammationNonspecific marker of inflammation Increased in many patients with CADIncreased in many patients with CAD Chronic exposure to CRP triggers the Chronic exposure to CRP triggers the

rupture of plaquesrupture of plaques

Etiology and PathophysiologyEtiology and Pathophysiology

►Endothelial alteration Endothelial alteration Platelets are activated Platelets are activated Growth factor stimulates smooth muscle Growth factor stimulates smooth muscle

proliferationproliferation Cell proliferation entraps lipids, which Cell proliferation entraps lipids, which

calcify over time and form an irritant to calcify over time and form an irritant to the endothelium on which platelets the endothelium on which platelets adhere and aggregateadhere and aggregate

Etiology and PathophysiologyEtiology and Pathophysiology

►Endothelial alteration Endothelial alteration Thrombin is generated Thrombin is generated Fibrin formation and thrombi occurFibrin formation and thrombi occur

Response to Endothelial Response to Endothelial InjuryInjury

Fig. 33-3

Stages of Development in Stages of Development in AtherosclerosisAtherosclerosis

Fig. 33-4

Etiology and PathophysiologyEtiology and PathophysiologyCollateral CirculationCollateral Circulation

►Analogous to “detours” around Analogous to “detours” around atherosclerotic plaquesatherosclerotic plaques

►Occur normally in coronary circulationOccur normally in coronary circulation►But collaterals increase in the But collaterals increase in the

presence of chronic ischemiapresence of chronic ischemia►When occlusion occurs slowly over a When occlusion occurs slowly over a

long period, there is a greater chance long period, there is a greater chance of adequate collateral circulation of adequate collateral circulation developingdeveloping

Collateral CirculationCollateral Circulation

Fig. 33-5

Risk Factors for Coronary Artery Risk Factors for Coronary Artery DiseaseDisease

►Risk factors can be divided:Risk factors can be divided: Unmodifiable risk factorsUnmodifiable risk factors Modifiable risk factorsModifiable risk factors

Risk Factors for Coronary Artery Risk Factors for Coronary Artery DiseaseDisease

►Unmodifiable risk factors:Unmodifiable risk factors: AgeAge GenderGender Ethnicity Ethnicity Genetic predispositionGenetic predisposition

Risk Factors for Coronary Artery Risk Factors for Coronary Artery DiseaseDisease

►Modifiable risk factors:Modifiable risk factors: Elevated serum lipidsElevated serum lipids HypertensionHypertension SmokingSmoking ObesityObesity Physical inactivityPhysical inactivity Diabetes mellitusDiabetes mellitus Stressful lifestyleStressful lifestyle

Diabetes TreatmentDiabetes Treatment

► Prescribed Meal Plan (sit down with a Dietitian)Prescribed Meal Plan (sit down with a Dietitian)► Home Blood Sugar monitoring Home Blood Sugar monitoring ► Regular exercise – at least 150 mins./wklyRegular exercise – at least 150 mins./wkly► ? Medications – pills or Insulin or both? Medications – pills or Insulin or both► Ongoing Education- Diabetes classesOngoing Education- Diabetes classes► Support – family and friendsSupport – family and friends► Physician follow-up or Specialist referralPhysician follow-up or Specialist referral

A person with Diabetes is A person with Diabetes is considered high risk like someone considered high risk like someone who has already had a heart who has already had a heart attack!attack!

Stress Stress - - “We do not laugh because we’re “We do not laugh because we’re happy – we’re happy because we laugh”happy – we’re happy because we laugh” William William

James James

► Stress may not be the main Stress may not be the main cause of disease ……. but, cause of disease ……. but, managing stress helps us;managing stress helps us;

maintain health maintain health deal with health problems.deal with health problems.Anger, anxiety and depressionAnger, anxiety and depression

are major emotions that are major emotions that need to be dealt with for a need to be dealt with for a healthy heart healthy heart

““75% of all good health 75% of all good health is under our control!”is under our control!”

Risk Factors for Coronary Artery Risk Factors for Coronary Artery DiseaseDisease

►Health PromotionHealth Promotion Identification of high-risk personsIdentification of high-risk persons Management of high-risk personsManagement of high-risk persons

►Risk factor modification Risk factor modification

Physical fitnessPhysical fitness Health education in schoolsHealth education in schools Nutrition (weight control, ↓ fat, ↓ chol Nutrition (weight control, ↓ fat, ↓ chol

intake)intake) Cholesterol-lowering medicationsCholesterol-lowering medications

Types of AnginaTypes of Angina

►Results when the lack of oxygen Results when the lack of oxygen supply is temporary and reversiblesupply is temporary and reversible

►Types of AnginaTypes of Angina Stable AnginaStable Angina Prinzmetal AnginaPrinzmetal Angina Unstable AnginaUnstable Angina

Coronary ArteryCoronary Artery

Stable Angina PectorisStable Angina Pectoris

►Chest pain occurs intermittently over a long Chest pain occurs intermittently over a long period with the same pattern of onset, period with the same pattern of onset, duration, and intensity of symptomsduration, and intensity of symptoms

►Can be controlled with medications on an Can be controlled with medications on an outpatient basisoutpatient basis

►Pain usually lasts 3 to 5 minutesPain usually lasts 3 to 5 minutes Subsides when the precipitating factor is Subsides when the precipitating factor is

relievedrelieved Pain at rest is unusualPain at rest is unusual

Silent IschemiaSilent Ischemia

►80 % of patients with myocardial 80 % of patients with myocardial ischemia are asymptomatic (with pain ischemia are asymptomatic (with pain or without pain the ischemia has the or without pain the ischemia has the same prognosis)same prognosis)

Prinzmetal’s AnginaPrinzmetal’s Angina

►Occurs at rest usually d/t spasm of Occurs at rest usually d/t spasm of major coronary arterymajor coronary artery

►Spasm may occur in the absence of Spasm may occur in the absence of CADCAD

Unstable AnginaUnstable Angina

►Angina that is:Angina that is: New in onsetNew in onset Occurs at restOccurs at rest Has a worsening patternHas a worsening pattern Unpredictable Unpredictable Considered to be an acute coronary Considered to be an acute coronary

syndromesyndrome Associated with deterioration of a once stable Associated with deterioration of a once stable

atherosclerotic plaqueatherosclerotic plaque

Clinical Manifestations Clinical Manifestations AnginaAngina

►Chest pain or discomfort (d/t ischemia)Chest pain or discomfort (d/t ischemia) A strange feeling, pressure, or ache in the A strange feeling, pressure, or ache in the

chestchest Constrictive, squeezing, heaving, choking, Constrictive, squeezing, heaving, choking,

or suffocating sensationor suffocating sensation Indigestion, burningIndigestion, burning

However…However…

►Up to 80% of patients with myocardial Up to 80% of patients with myocardial ischemia are asymptomaticischemia are asymptomatic

►Associated with diabetes mellitus and Associated with diabetes mellitus and hypertensionhypertension

Location of Chest PainLocation of Chest Pain

Fig. 33-12

Diagnostic StudiesDiagnostic StudiesAnginaAngina

►ECGECG►Coronary angiographyCoronary angiography►Cardiac markers (CK MB, Troponin)Cardiac markers (CK MB, Troponin)►Treadmill exercise testing (stress test)Treadmill exercise testing (stress test)►Serum lipid levelsSerum lipid levels►C-reactive protein (CRP)C-reactive protein (CRP)►Nuclear imagingNuclear imaging

Coronary AngiographyCoronary Angiography

► A diagnostic test using A diagnostic test using x-rays to record the x-rays to record the passage of a contrast dye passage of a contrast dye in the heartin the heart

► To identify the presence, To identify the presence, location and nature of any location and nature of any coronary artery diseasecoronary artery disease

► The heart valves and The heart valves and heart muscle can also be heart muscle can also be assessedassessed

Coronary AngiogramCoronary Angiogram

Coronary Angioplasty Video Coronary Angioplasty Video LinkLink

►http://www.healthscout.com/animationhttp://www.healthscout.com/animation/1/38/main.html/1/38/main.html

Collaborative CareCollaborative CareAnginaAngina

►Treatment for stable angina:Treatment for stable angina: oxygen demand and/or oxygen demand and/or oxygen supply oxygen supply Nitrate therapyNitrate therapy Stent placementStent placement

Collaborative CareCollaborative CareAnginaAngina

►Treatment for stable angina:Treatment for stable angina: Percutaneous coronary interventionPercutaneous coronary intervention AtherectomyAtherectomy Laser angioplastyLaser angioplasty Myocardial revascularization (CABG)Myocardial revascularization (CABG)

Coronary Artery Bypass Coronary Artery Bypass SurgerySurgery

► Is open heart surgery, Is open heart surgery, which a bypass ( detour) which a bypass ( detour) is made to go around an is made to go around an area of blockage in a area of blockage in a coronary arterycoronary artery

► Bypasses are usually Bypasses are usually taken from the leg veins taken from the leg veins or an artery from the or an artery from the inside of the chest wallinside of the chest wall

Collaborative CareCollaborative CareAnginaAngina

►Drug TherapyDrug Therapy Antiplatelet aggregation therapyAntiplatelet aggregation therapy

►Aspirin: drug of choice (for MI prevention)Aspirin: drug of choice (for MI prevention)►First line of treatment for anginaFirst line of treatment for angina

Collaborative CareCollaborative CareAnginaAngina

►Drug TherapyDrug Therapy NitratesNitrates

►1st line therapy for treatment of acute anginal 1st line therapy for treatment of acute anginal symptomssymptoms

►Dilation of vesselsDilation of vessels

Collaborative CareCollaborative CareAnginaAngina

►Drug TherapyDrug Therapy -Adrenergic blockers-Adrenergic blockers Calcium channel blockersCalcium channel blockers

Collaborative CareCollaborative CareAnginaAngina

►Percutaneous coronary interventionPercutaneous coronary intervention Surgical intervention alternativeSurgical intervention alternative Performed with local anesthesiaPerformed with local anesthesia Ambulatory 24 hours after the procedureAmbulatory 24 hours after the procedure

Collaborative CareCollaborative CareAnginaAngina

►Stent placementStent placement Used to treat abrupt or threatened abrupt Used to treat abrupt or threatened abrupt

closure and restenosis following PCIclosure and restenosis following PCI

The Coronary Stent The Coronary Stent ProcedureProcedure

► A coronary stent is a A coronary stent is a small tubular wire small tubular wire object inserted into object inserted into a coronary artery at a coronary artery at the time of the time of angioplasty to keep angioplasty to keep the previously the previously narrowed artery narrowed artery open open

Collaborative CareCollaborative CareAnginaAngina

►AtherectomyAtherectomy The plaque is shaved off using a type of The plaque is shaved off using a type of

rotational bladerotational blade Decreases the incidence of abrupt closure Decreases the incidence of abrupt closure

as compared with PCIas compared with PCI

Collaborative CareCollaborative CareAnginaAngina

►Laser angioplastyLaser angioplasty Performed with a catheter containing Performed with a catheter containing

fibers that carry laser energyfibers that carry laser energy Used to precisely dissolve the blockageUsed to precisely dissolve the blockage

Collaborative CareCollaborative CareAnginaAngina

►Myocardial revascularization (CABG)Myocardial revascularization (CABG) Primary surgical treatment for CADPrimary surgical treatment for CAD Patient with CAD who has failed medical Patient with CAD who has failed medical

management or has advanced disease is management or has advanced disease is considered a candidateconsidered a candidate

Clinical Manifestations Clinical Manifestations Myocardial InfarctionMyocardial Infarction

►PainPain Severe, immobilizing chest pain not Severe, immobilizing chest pain not

relieved by rest, position change, or relieved by rest, position change, or nitrate administrationnitrate administration

►The hallmark of an MIThe hallmark of an MI

Serum Cardiac Markers Serum Cardiac Markers (Lewis p.817)(Lewis p.817)

► Creatine Kinase (creatine phosphokinase)Creatine Kinase (creatine phosphokinase) (CK- (CK-MB)MB) Increased in > 90% of MI patients.Increased in > 90% of MI patients. Begins to rise 4-6 hoursBegins to rise 4-6 hours Peaks 24 hoursPeaks 24 hours Returns to normal in 2 - 3 daysReturns to normal in 2 - 3 days

► TroponinTroponinMyocardial muscle protein released after an injuryMyocardial muscle protein released after an injuryTroponin T and Troponin I are cardiac specific Troponin T and Troponin I are cardiac specific

indicators of an MIindicators of an MIMuch more specific than CK-MBMuch more specific than CK-MBRises quickly and remains elevated for 2 weeksRises quickly and remains elevated for 2 weeks

Serum Cardiac MarkersSerum Cardiac Markers

►Lactic Dehydrogenase (LD or LDH)Lactic Dehydrogenase (LD or LDH) Found in heart muscle as well as others Found in heart muscle as well as others It is increased in >90% of MI patients. It is increased in >90% of MI patients.  BBegins to rise 24 hoursegins to rise 24 hours Peaks in 3 daysPeaks in 3 days Returns to normal in 8-9 daysReturns to normal in 8-9 days

Diagnostic Cardiac enzymesDiagnostic Cardiac enzymes(See Lewis p. 817 Figure 33-15 (See Lewis p. 817 Figure 33-15

also)also)

Clinical ManifestationsClinical Manifestations

►Acute Coronary Syndrome (ACS)Acute Coronary Syndrome (ACS) Develops when the oxygen supply is Develops when the oxygen supply is

prolonged and not immediately reversibleprolonged and not immediately reversible

Clinical ManifestationsClinical Manifestations

►ACS encompasses:ACS encompasses: Unstable anginaUnstable angina Myocardial infarction (MI)Myocardial infarction (MI)

Relationships Among CAD, Relationships Among CAD, Stable Angina, and MIStable Angina, and MI

Fig. 33-8