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8/2/2019 Presentation 1 IHD ILA Pathology
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A 53-year-old man presents with recurrent chest
pain that has gotten progressively worse over thelast several weeks. He says that approximately a
year ago the pain would occasionally occur when
he was mowing his yard but now the painsometimes occurs while he is sitting in a chair at
night reading a book. The pain which is localized
over the sternum, lasts much longer now than it
did a few months ago.
What type of disease does this individual have at
present ?
8/2/2019 Presentation 1 IHD ILA Pathology
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I. Ischemic heart disease
Coronary heart disease orCoronary artery disease.
Definition:
A group of closely related disorders
caused by myocardial ischemia due to an
imbalance between oxygen demand and
supply by the blood.
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Etiology of IHD
1. Reduced coronary blood flow (90% 0f cases)a- Disease of the coronary:
mostlydue to atherosclerosis associated with
thrombosis or vasospasm.Other uncommon causes include emboli from IE,
vasculitis, vasospasm, coronary ostialnarrowing as in syphilis.
b- severe tachycardia (shortening of diastole)
C- Aortic valve disease as stenosis or regurge
D- severe hypotension as in shock.
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Etiology of IHD
2. Increased myocardial demand.eg
tachycardia, myocardial hypertrophy.
3.Hypoxia due to diminished oxygentransport eg severe anemia, advanced
lung disease, and cyanotic congenital
heart disease.
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Pathogenesis of ischemic injury:-
Hypoxia: is the most important factor leading to ATP
depletion, increase cytosolic calcium and shift to anaerobic
respiration resulting into either reversible cell injury (cloudy
swelling and fatty change) or irreversible cell injury(necrosis)
Failure to remove waste products (metabolites) e.g.,
accumulation of metabolites may explain the pain of muscleischemia.
8/2/2019 Presentation 1 IHD ILA Pathology
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Classification of
ischemic heart disease
1.Angina pectoris.
2. Myocardial infarction.
3. Chronic ischemic heart disease
with congestive heart failure.
4. Sudden cardiac death.
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I. ANGINA PECTORIS
A clinical syndromecharacterized by
intermittent or episodic
chest pain or discomfortcaused by:
transient and reversible
myocardial ischemia
which is not severe enough to
cause death of myocardial
muscles.
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crushing , squeezing,constricting or knife like.
It may radiate to the
back , neck or left arm.
PAIN
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Types of Angina pectoris
1- Stable (typical) angina.
2-Variant (Prinzmetal) angina.
3-Unstable angina.
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Angina pectoris
Stable AnginaIt is associated
with chronic fixed
atheroscleroticnarrowing of the
coronaries.Variant AnginaIt is associated with
coronary artery
spasm near an
advancedatherosclerotic
plaque .
Unstable AnginaIt is precipitated by
fissuring or disruption of
the fixed atherosclerotic
plaque with superadded
thrombosis or
vasospasm but thelumen is still opened.
No Myocardial
Necrosis
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II. MYOCARDIAL INFARCTION
Definition: Development of an area of
coagulative necrosis of the cardiac muscle
due to sudden complete occlusion ofarterial supply with deficient collateral
circulation.
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MI - Types
Transmural
Full thickness
Superimposed thrombus in
atherosclerosis
Focal damage
Sub-endocardial
Inner 1/3 to half of
ventricular wall Decreased circulating blood
volume( shock,
Hypotension, Lysed
thrombus)
Circumferential
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Transmural infarct Subendocardial infarct
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MI- Microscopic featuresOne-day-oldinfarct
coagulative necrosis
wavy fibers
Up to 3 days duration
Neutrophilic infiltrate
1 -2 weeks
Granulation tissue
Scar
>3 weeks
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III. CHRONIC ISCHEMIC HEART
DISEASE
Definition:Development of progressive
congestive heart failure in elderly patients
with multivessel coronary atheroscleroticnarrowing.
Mechanism: It occurs due to post infarction
cardiac decompensation that followsexhaustion of the hypertrophied viable
myocardium.
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Morphology:
*Enlarged heart due to hypertrophy and
dilatation of all chambers.
*Atherosclerotic coronary narrowing.
*Multiple areas of fibrous scar due to
healed myocardial infarction.
*Thickened endocardium covered by
thrombi
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Clinical picture:
1. Progressive congestive heart failurein patients with previous attacks ofangina &/ or MI.
2. Arrythmias are common.3. Death caused by
- Arrythmias
- CHF.
- Acute myocardial infarction
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IV. SUDDEN CARDIAC DEATH
Definition: unexpected cardiac death within
one hour of symptom onset.
Due to Fatal
arrythmias
especilallyventricular
fibrillation
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Mechanism: Lethal cardiac arrythmias
especially ventricular fibrillation.
Morphology:
Complicated coronary atherosclerotic
plaque
recent or old MI or scarring.