Coronary Artery Disease - PowerPoint - PowerPoint by j1jnZ0D

VIEWS: 60 PAGES: 31

									Coronary Artery
    Disease
Andrew C Rankin

Glasgow Royal Infirmary
    Coronary Artery Disease
               Angina


                          Myocardial
Asymptomatic
                          Infarction

               Unstable
                angina
                       Atherosclerosis Timeline
                                                                      Complicated
     Foam            Fatty       Intermediate               Fibrous     Lesion/
     Cells          Streak          Lesion    Atheroma      Plaque      Rupture




                                  Endothelial Dysfunction
         From First                      From Third           From Fourth
          Decade                           Decade               Decade


Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
Risk Factors for Atherosclerotic Disease

  Non-modifiable               Modifiable
   Age                         Cigarette smoking
                                Diabetes mellitus
   Family history
                                Hyperlipidemia
   Sex
                                Hypertension
                                Obesity
                                Physical inactivity


           Hoeg JM. JAMA. 1997;277:1387–1390.
    Coronary arteries

                    Left Main Coronary
Right Coronary      Artery
Artery
                     Diagonal Artery

                     Left Anterior
Posterior            Descending Artery
Descending Artery
   Coronary Angiography
Left coronary artery
   Coronary Angiography
Right coronary artery
                         Death rates from CHD, (per 100,000) men and women aged 35-74, 1994, selected countries
             Latvia
Russian Federation
         Lithuania
          Hungary
   Czech Republic
            Ireland
          Romania
           Finland
               UK
           Poland
          Norway
         Denmark
          Sweden
             USA
           Austria
         Germany
         Australia
          Canada
      Netherlands
      Luxembourg
           Greece
              Italy
           Mexico
                                                                                                                  men
         Portugal
            Spain                                                                                                 women
           France
            Japan
                              800             600             400             200            0             200            400
                  1000
     R


P         T wave

    Q S
       Mechanisms of Action of
        Anti-Anginal Drugs

Reduce Cardiac Workload
• Slow Heart Rate
• Reduce Force of Contraction
• Reduce Pre-load / After-load


Improve Blood Supply
• Coronary Vasodilatation
       Drug Therapy for Angina
Antianginals
Adalat LA       Coracten     Isocard         Nitromin        Syscor MR
Adipine MR      Cordilox     Isoket          Nitronal        Tenif
Adizem-XL       Corgard      Isordil         Percutol        Tenormin
Angiopine MR    Coro-Nitro   Istin           Plendil         Tensipine MR
Angitil SR      Deponit      Lopresor        Posicor
                                                             Tildiem LA
                Dilzem SR    MCR-50          Probeta LA
Beta-Adalat                                                  Totamol
                Elantan LA   Minitran        Sectral
Beta-Prograne                                Securon SR      Trandate
                Emcor        Monit
Betaloc                                      Slow-Trasicor   Transiderm
                Eucardic     Mono-Cedocard
Betim                                        Slozem          Trasicor
                Glytrin      Monocor
Blocadren       Ikorel                       Sorbichew       Univer
Britiazim                    Monomax         SorbidSA        Viazem XL
                Imdur        Myocardol
Cardene         Inderal LA                   Sorbitrate      Visken
                             Nitro-Dur       Suscard
Cardilate MR    Isib 60XL
                             Nitrocine       Sustac
Cedocard        Ismo
                             Nitrolingual
          Drug Therapy for Angina
Beta-blockers        Calcium     Nitrates          K+ Channel
                     Antagonists                   Activator
  Acebutolol    I      Verapamil     GTN           Nicorandil
  Atenolol
  Bisoprolol    II     Amlodipine    Isosorbide
  Carvedilol           Felodipine    Dinitrate
  Labetolol            Nicardipine
  Metoprolol           Nifedipine    Isosorbide
  Nadolol              Nisoldipine   Mononitrate
  Oxprenolol
  Pindolol      II     Diltiazem
  Propranolol
  Timolol
PCI / PTCA = Angioplasty
Coronary stents
Acute Coronary
  Syndromes
 Acute Myocardial Infarction
 Unstable angina
  • Rest pain
  • Crescendo angina
  • New onset angina
 Role of Platelets in Thrombus Formation
         in Acute Ischemic Events


             Lipid
             Core
Atherosclerotic      Plaque    Platelet Adhesion,   Thrombus    Thrombotic
    Vessel           Rupture    Activation, and     Formation    Occlusion
                                  Aggregation

                                                                   MI
                                                                 Stroke
                                                                Vascular
                                                                 Death
ST depression
ST elevation
                                   y b
                                    o i
                                   Mo l
                                     gn
                                   r n
                                   oi
                                    pn
                                   To
                                   KT
                                    ,
                                   CSA
                                   D
                                   LH
RELATIVECONCENTRATION

                                   ol
                                    r
                                    m
                                   Na



                         6 14 3579
                          2 2
                        0 18 24681   0
                          o
                          Hu
                           r
                           s    Dy
                                 as
                           I ET IF T
                           M EF NC
                           T ARA  R
             Complications of Acute MI

Extension / Ischemia   Arrhythmia
                                           Pericarditis


                       RV     LV


Expansion / Aneurysm     Acute MI           RV Infarct




Mechanical             Heart Failure   Mural Thrombus
ISIS-2.Lancet 1988;11:349–360
       Acute coronary syndrome


   ST elevation        No ST elevation



Thrombolytic therapy
       PCI
                              ?
Thrombolysis for ACS
without ST elevation?
   It doesn’t work!
e.g. Fibrinolytic Therapy Trialist (1994)
     • 3563 patients with suspected AMI
     • ST segment depression
     • Mortality 15.2% vs 13.8%
        ECG and outcome in ACS
%                                              ST 
        T-wave inversion
        ST-segment depression
%       ST-segment elevation
                                   P  0.001
%
                                               ST 
%

%                                     T-wave
                                      inversion
%
    0   30      60       90     120            150    180
              Days from Randomization
                                                      GUSTO IIb
Troponin level and mortality in ACS
                        8                                                                  7.5 %
                        7
 Mortality at 42 Days




                                                                                6.0 %
                        6
                        5
                        4                               3.4 %       3.7 %
                        3
                        2
                                           1.7 %
                              1.0 %
                        1
                              831         174          148         134          50         67
                        0
                            0 to <0.4   0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0    9.0
                                                   Cardiac troponin I (ng/ml)
Myocardial infarction redefined
    WHO definition: (2 of 3)
    • Typical symptoms (chest pain)
    • Typical ECG changes (Q waves)
    • Enzyme rise
    ESC/ACC redefinition 2000
    • Troponin rise, with one of:
    • Chest pain
    • ECG changes (Q waves or ST segment)
    • PCI
Presentation               Chest pain
Working
Diagnosis       Acute coronary syndrome


ECG         ST elevation           No ST elevation
                +



                                   +      -
Troponin

               STEMI    NSTEMI
Final
diagnosis   Myocardial Infarction Unstable Angina

								
To top