ischemic-heart-disease2437-160122102507.pptx

Ischemic heart disease ppt

1. Ischemic Heart Disease

2. Coronary artery disease

3. Risk factors for coronary artery disease

4. Risk Factors for Coronary artery disease Non-modifiable Age Family history Sex Modifiable Cigarette smoking Diabetes mellitus Hyperlipidemia Hypertension

5. Other less important risk factors

6. Pathogenesis of coronary artery disease

7. Atherosclerosis The underlying pathogenesis of coronary arterial disease is atherosclerosis Atherosclerosis = “Hardening of the vessels”

8. Atherosclerosis

9. Smoking Blood pressure Cholesterol Diabetes mellitus Other factors Atherosclerosis Thrombosis Heart attack Brain attack Other vascular Development of atherosclerosis

10. Atherosclerosis The key processes in atherosclerosis are intimal thickening lipid accumulation These processes will produced the atheromatous plaque The underlying pathogenesis of coronary arterial disease is atherosclerosis Atherosclerosis = “Hardening of the vessels”

11. Atheromatous plaque

12. Atheroma in coronary artery

13. Atheromatous plaque/ Atheroma Fatty streak Atheroma

14. Response to Injury Hypothesis Atherosclerosis is a chronic inflammatory response of the arterial wall initiated by some form of injury to the endothelium

15. Smooth endothelium

16. Chronic repetitive injury Smoking Hypertension Hyperlipidemia Endothelial injury

17. Response to injury

18. Pathogenesis of myocardial ischemia

19. Coronary artery atherosclerosis Most of the patients with coronary artery disease has coronary atherosclerosis which cause obstruction to blood flow

20. Effect of atherosclerosis

21. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

22. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

23. Asymptomatic

24. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

25. Sudden death May be the first manifestation in 25% of patients 20% of patients with AMI will died before reaching hospital Most of these death are caused by ventricular fibrillation

26. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

27. Angina Pectoris Imbalance of oxygen supply and demand Decreased blood flow to myocardium Results in chest pain Switch to anerobic metabolism Lactic acid build up Kinins, histamine, other substances released Nerve fibers are stimulated

28. Angina Pectoris

29. Typical Angina

30. Typical Angina

31. Typical Angina

32. Canadian Cardiovascular Society (CCS) ANGINA Functional Class Symptoms I Normal ordinary activity Angina with strenuous exercise II Slight limitation of ordinary activity III Marked limitation of ordinary activity IV Inability to perform any activity without symptom. May be present at rest

33. Typical Angina

34. Types of angina Angina Stable angina Prinzmetal variant angina Unstable angina

35. Stable angina Also called exertional angina The lumen of coronary artery is narrowed and hard; thus, dilation in response to increased demand is impossible

36. Stable angina Initiated by known amount of activity Same activity tends to produce same symptoms Produced by physical activity emotional excitement cause of increased cardiac workload Relieved by rest, Nitrate

37. Printzmetal angina Also called variant angina, Prinzmetal’s variant angina An uncommon pattern of episodic angina that occurs at rest Due to coronary artery spasm.

38. Printzmetal angina Occurs without a precipitating event, usually at the same time of day Often awakens patient from sleep Unpredictable, occurs most often at rest

39. Coronary Angioplasty Before After

40. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

41. Acute coronary syndrome Acute Coronary Syndrome Unstable angina Non-ST Elevation Myocardial Infarct Acute Myocardial infarct

42. ATHEROMATOUS PLAQUE PLAQUE RUPTURE

43. ATHEROMATOUS PLAQUE PLAQUE RUPTURE

44. ATHEROMATOUS PLAQUE PLAQUE RUPTURE PLAQUE RUPTURE

45. Clinical features of Acute Myocardial Infarction Angina Prolonged Not relieved by usual dose of nitrates Sweating Nausea and vomiting Palpitation Dyspnea Sudden death

46. Acute coronary syndrome Angina occurs at rest or on minimum exertion Not relieved by usual doses of GTN The pain last longer (> 20 minutes) Increasing in duration/severity/frequency

47. Acute Coronary Syndrome

48. ECG changes of AMI

49. Anterior myocardial infarct

50. Inferior myocardial infarct

51. Cardiac enzymes Myoglobulin Troponin Creatinine kinase (MB) ALT Lactate dehydrogenase

52. Cardiac Enzymes in ACS

53. Cardiac Enzymes in ACS Test Onset Peak Duration Myoglobulin 1-4 hours 6-7 hours 24 hours Troponin 3-12 hours 18-24 hours Up to 10 days CK-MB 3-12 hours 18-24 hours 36-48 hours LDH 6-12 hours 24-48 hours 6-8 days

54. Acute Coronary Syndrome

55. Non ST elevation MI Typical chest pain Raised cardiac enzymes NO ST elevation in ECG But may have other ECG changes

56. NSTEMI: ECG changes

57. Acute Coronary Syndrome

58. Unstable angina Chest pain NO cardiac enzyme changes NO ST elevation in ECG

59. Acute coronary syndrome Acute Coronary Syndrome Unstable angina Non-ST Elevation Myocardial Infarct Acute Myocardial infarct

60. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

61. Heart failure In recurrent myocardium ischemia, the myocardium will loss function This will progress to reduced left ventricular function and cause heart failure

62. Signs and symptoms Orthopnea Reduced effort tolerance Paroxysmal nocturnal dyspnea Raised JVP Acute pulmonary edema

63. Orthopnea Unable to lie flat Sometimes need to sit up to sleep Severity judged by number of pillows required to sleep on

64. Paroxysmal Nocturnal Dyspnea waking up in about 2-3 am breathlessness Lying Down

65. Acute pulmonary edema

66. ECHO: Poor LVEF Dilated LV Dilated LA Globally poor LV contraction

67. Treatment

68. End of Phase II 11.8.09 Lifestyle modifications Smoking Diabetes Male Hypertension Obesity Lack of exercise Stress

69. Lifestyle modifications

70. Lifestyle modifications

71. Antiplatelet Aspirin ADP receptor antagonist Ticlopidine Clopidogrel

72. Antiplatelet Chronic angina Aspirin for life ADP receptor antagonist if aspirin intolerable Acute coronary syndrome Dual antiplatelet

73. Thrombolytic Lyse the clot that block the blood flow Examples Streptokinase rTPA Only in acute myocardial infarct

74. Anticoagulant - Heparin Heparin Low molecular weight heparin oligosaccharides (fondaparinux) Heparinoid

75. Anticoagulant - Heparin Used in acute coronary syndrome Currently favors oligosaccharides (fondaparinux) Less bleeding complications Single daily injection Halal

76. COX (cyclo-oxygenase) ADP (adenosine diphosphate) TXA 2 (thromboxane A 2 ) Thienopyridines ASA COX ADP ADP C GPllb/llla (Fibrinogen receptor) Collagen thrombin TXA 2 Activation TXA 2 ASA Synergistic Mode of Action with Clopidogrel and ASA 1 1. Schafer AI. Am J Med 1996; 101: 199–209.

77. Glycoprotein IIb/IIIa inhibitors Examples Abciximab Tirofiban Eptifibatide Used mainly in Unstable angina NSTEMI

78. Primary PCI - 1

79. Aspirated clot

80. Primary PCI - 2

81. PCI of coronary artery The narrowing was openned with a angioplasty balloon A stent was inflated after the balloon angioplasty

82. Coronary bypass surgery

83. Coronary artery disease ACE inhibitor/Angiotensin receptor blocker Beta Blocker Calcium channel blocker if not tolerable to beta blocker

84. Treat the concomitant conditions Hypertension Diabetes Mellitus Hyperlipidemia

85. Summary

86. Smoking Blood pressure Cholesterol Diabetes mellitus Other factors Atherosclerosis Thrombosis Heart attack Brain attack Other vascular Development of atherosclerosis

87. Presentation of coronary heart disease Asymptomatic Chronic stable angina Acute coronary syndrome (ACS) Death (MI = Myocardial Infarction) Unstable angina Non ST elevation MI ST elevation MI Heart failure

88. Acute Coronary Syndrome

89. End of Phase II 11.8.09