ISCHEMIC HEART DISEASE

Akram Saleh MD, FRCPDirector of cardiology unit

Consultant Invasive Cardiologist

15-Oct-2012

Ischemic Heart Disease (IHD)

When to suspect patient with IHD

Basic: coronary circulation

Myocardial oxygen supply and demands

Causes of IHD

Management

Case presentation

A 65 Year old male, presented to outpatient clinic complaining of chest pain of 5 months duration.

What are the possible anatomical causes of chest pain?

The pain is retrosternal, compressive in nature, precipitated by wakening of 400 meter , relieved by rest, radiated to left shoulder, associated with sweating.

Patient is diabeticAnd smoker

On examination: Blood pressure:160/100. pulse rate: 88 bpmHeart auscultation : normalWHAT IS THE PROBLEB?What is abnormal physical findings?What to do? Investigations

Coronary Anatomy

Ischemic Heart Disease

demand

supply

1- Heart rate

2- Contractility

3- Wall tension

4- Muscle mass (wall thickness

1- Coronary flow (patency of coronary artery)

2- Hemoglobuline level

3- Myocardial oxygen extraction

4- Arterial oxygen saturation

Causes of coronary artery disease

95% Atherosclerosis Risk factors:

5% Nonatherosclerosis

Risk Factors for Cardiovascular DiseaseRisk Factors for Cardiovascular Disease

Modifiable Hypertension Smoking Hyperlipidaemia

Raised LDL-C Low HDL-C Raised triglycerides

Diabetes mellitus Dietary factors Lack of exercise Obesity Homocysteinemia Lipoprotein a Gout Thrombogenic factors: fibrinogen, factors V,VII Excess alcohol consumption

Non-modifiable Personal history

of CVD

Family history of CVD

Age: M>45, F>55

Gender M>F (Premenopausal)

Personality type A

Genetic factors: ACE gene

Upregulation of endothelialadhesion molecules

Increased endothelial permeability

Migration of leucocytes into the artery wall

Leucocyte adhesion

Lipoprotein infiltration

Endothelial Dysfunction in Atherosclerosis

Formation of foam cells

Adherence and entry of leucocytes

Activation of T cells

Migration of smooth muscle cells

Adherence and aggregation of platelets

Fatty Streak Formation in Atherosclerosis

Formation of the fibrous cap

Accumulation ofmacrophages

Formation ofnecrotic core

Formation of the Complicated Atherosclerotic Plaque

Characteristics of Unstable and Stable Plaque

Thin fibrous cap

Inflammatory cells

FewSMCs

Erodedendothelium

Activatedmacrophages

Thickfibrous cap

Lack ofinflammatory cells

Foam cells

Intactendothelium

MoreSMCs

Libby P. Circulation. 1995;91:2844-2850.

Unstable Stable

AHA-Classification

Gottdiener JS. In: ACCSAP 1997-98 by the ACC and AHA

Clinical Manifestations of Atherosclerosis

Coronary heart disease Asymptomatic Angina pectoris, variant angina Myocardial infarction, Unstable angina Heart failure (HF) Arrhythmias Sudden cardiac death.

Asympt sudden death

IHD-clinicopathological correlation

1- stable angina: stenosis > 70% luminal narrowing

2-variant angina: increase coronay tone

30% normal coronaries

3-unstable angina: rupture plaque

subocclusive thrombus

progress to myocardial infarction 15-30%

4-myocardial infarction: rupture plaque

occlusive thrombus

Angina Chest Pain:

Clinical Diagnosis

CAUSES OF ANGINA

Reduced Myocardial O2 Supply1-Coronary artery disease

2-Sever Anemia

Increased Myocardial O2 Demand1-Left Ventricular Hypertrophy:

hypertension

aortic stenosis

hypertrophic cardiomyopathy

2- Rapid Tachyarrhythmias

Differential diagnosis of angina

1- Neuromuscular disorder

2- Respiratory disorders

3-Upper GI disorder

4- Psychological

5- Syndrome X:

Typical angina with normal coronary angio

? Increase tone or decrease coronary vasodilatation

excellent prognosis

antianginal therapy is rarely effective

Case presentation

A50 year old male presented to emergency room complaining of sudden sever chest pain of 1 hour duration. It is retrosternal, compressive, and radited to left shoulder and arm.

Associated with sweating, nausea and vomiting

On examination: patient is anxious, in pain, sweaty.BP: 100/60. PULSE: 120 BPM, RR: 26/minChest: basal crepitations

What is the most likely diagnosispathophysiology

Characteristics of Unstable( RUPTURE-PRONE PLAQUE) and Stable Plaque

Thin fibrous cap

Inflammatory cells

FewSMCs

Erodedendothelium

Activatedmacrophages

Thickfibrous cap

Lack ofinflammatory cells

Foam cells

Intactendothelium

MoreSMCs

Adapted with permission from Libby P. Circulation. 1995;91:2844-2850. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Unstable Stable

PATHOGENESIS OF ACS

Plaque rupture-----Platelet adhesion---activation---aggregation

THROMBOSIS

1- Primary hemostasis: Initiated by platelet

platelets adhesion, activation, and aggregation---platelet plug

2- Secondary hemostasis:

activation of the coagulation system---fibrin clot.

These two phases are dynamically interactive:

Platelet can provide a surface for coagulation enzymes

Thrombin is a potent platelet activator

platelet

Gp 11B/111A

Thank you

Diagnosis of Myocardial Infarction

1-History2-ECG (Electrocardiogram): STMI and NSTMI Hyperacute T wave ST-segment elevation Q- wave T- inversion ST-segment depresion

normal ECG will not exclude MI3-Cardiac Marker: Troponin,CPK, myoglobulin,.. Troponin T,I: 4-6 Hr last 10-14 days CPK:4-6 Hr, peak 17-24hr, normal 72 hr MB(MM,BB) MB2/MB1 >1.5

Regions of the Myocardium

InferiorII, III, aVF

LateralI, AVL, V5-V6

Anterior / SeptalV1-V4

ST Elevation

ST segment Elevation MI

ST segment Elevation

Acute Inferior Wall MI

Acute Posterior Wall MI

Stable angina-Diagnosis

History : angina pectoris is clinical diagnosis Physical exam Electrocardiogram: 12 ECG, 24 ECG Stress ECG : diagnostic and prognostic information Radioactive studies: thalium scan,.. Echocardiography CT Coronary angiography Serum lipid( LDL, HDL, TG), FBG,CBC Coronary angiography

Imaging Techniques Used to Assess Atherosclerosis

Invasive techniques Coronary angiography Intravascular ultrasound (IVUS)

Non-invasive techniques Magnetic resonance imaging (MRI) Computed tomography (CT) Ultrasound (B-mode)

Intravascular Ultrasound (IVUS) Showing Atheromatous Plaque

Reproduced from Circulation 2001;103:604–616, with permission from Lippincott Williams & Wilkins.

Angiogram IVUS

atheroma

normal vessel

Coronary Angiographyof Stenotic Coronary Artery

6

Arrow indicates atherosclerosis (stenosis) of the coronary artery

Management goals of stable angina

To To improve prognosisimprove prognosis (mortality reduction) (mortality reduction) Modification of risk factorsModification of risk factors AspirinAspirin Lipid-lowering therapyLipid-lowering therapy ACE-InhibitorACE-Inhibitor Revascularization procedures (PTCA, CABG)Revascularization procedures (PTCA, CABG)

To To decrease anginal symptomsdecrease anginal symptoms Medical treatmentMedical treatment

ACC/AHA Guidelines. J Am Cardiol. 1999;33:2092-2197.

ESC Guidelines. Eur Heart J. 1997;18:394-413.

Treatment of stable angina

1- General measures

2- Medical therapy: Increase O2 supply

Decrease O2 demand

3-Revasularization: PCI (percutaneous coronary intervension)

CABG (coronary artery bypass grafting)

TREATMENT OF STABLE ANGINAGeneral Measures

Correction of established risk factors( reversible)

weight reduction (ideal body weight)

Areobic exercise: improve functional capacity, well-being sensation

Treatment of: anemia, thyrotoxicosis, arrhythmias,..

4.

MEDICAL THERAPY OF STABLE ANGINAPrognostic: Aspirin, Statines, ACEI

Symptomatic: Nitrate,B-,CA-blocker, (nicorandil, ranolazine, ivabradine)

INCREASE O2 Supply

1-Increase diastolic time: B-blocker

2-Decrease coronary tone: nitrate, ca-blocker

3-Decrease LV diastolic pressure: nitrate

4-Correct coronary stenosis: PCI, CABG

5-Increase O2 capacity of blood: transfusion if anemia

DECREASE O2 Demand

1-Decrease heart rate: B-blocker, ca-blocker

2-Decrease contractility: B-blocker, ca-blocker

3- Decrease wall tension (LV pressure and cavity radius): nitrate

4- metabolic: trimetazidine

Treatment in practice

1-General measures

2-Aspirin

3-Nitrate: S/L, Oral, dermal

3-B-blocker

4-Statins: LDL>100 mg/dl( 70mg/dl)

5-Ca-blocker

6-Angio :PTCA,CABG

New medical and invasive therapies for refractory angina

Inhibition of fatty acid metabolism: trimetazidine

Potassium channel activators: Nicorandil.

Ranolazine: interact with sodium channel

Ivabradine: SA inhibitor

Endothelin Receptor Blockers: bosentan ??

Testosteron: improve endoth dysfunction.

Enhanced external balloon counterpulsation

Spinal cord stimulation.

Laser revascularization, angiogenesis.

Prognosis of stable angina

mortality/year

2% single vessel-------12% left main stem

VARIANT ANGINA-PRINZMETAL ANGINA

Chest pain with ST-Segment elevationUsually at rest, Troponin: negativeFemale > male

Spasm of large epicardial coronary vessel during the attackVasospastic symptpms in other organs

Can cause arrhythmias and death

Treatment: CA-blocker, Nitrate

B-blocker is contraindicated

Prognosis: 5 year mortality < 5%