CoCo o a y ea t sease,ronary Heart Disease, Angina, MI ...
Transcript of CoCo o a y ea t sease,ronary Heart Disease, Angina, MI ...
Coronary Heart Disease, Co o a y ea t sease,Angina, MI, Embolism
Year 1 Cardiovascular System
Ranil de Silva FRCP PhDSenior Lecturer in Clinical Cardiology
How does coronary artery disease present?
o Sudden cardiac deatho Sudden cardiac deatho Acute coronary syndrome
– Acute myocardial infarction– Unstable anginag
o Stable angina pectorisfo Heart failure
o Arrhythmiao Arrhythmia
Epidemiology – Determinants of Risk
o Tobacco use, physical inactivity, harmful p y yuse of alcohol, unhealthy diet accounts results in:results in:– Hypertension
Ob it– Obesity– Diabetes mellitus– Hyperlipdaemia
o Responsible for ~80% of CHD
Global Burden of CVD
o Cardiovascular diseaseo Cardiovascular disease accounts for ~17M deaths per year.deaths per year.
o Leading cause of death in both developed and plow/medium income countries
o Leading cause of death in age <70yL di f d th io Leading cause of death in women
WHO Global Status Report on Non-communicable disease 2010
UK Burden of CHD
88 000 CHD d th t fo 88,000 CHD deaths per year, commonest cause of death
o CHD accounts for 18% deaths in men and 10% deaths in women <75y commonest cause of premature deathin women <75y, commonest cause of premature death
o While rates are falling UK mortality still greater thano While rates are falling, UK mortality still greater than most of Western Europe
Coronary Heart Disease Statistics 2010
UK MI Statistics (2009-10)( )
o 124,000 MI’s per yr, p y
o ~99,000 hospital , padmissions per year
o ~33,000 deaths per year (~6% of all deaths in UK)
o £3.6 billion per year
Epidemiology of Stable Anginap gy g
o Incidence increasingo Incidence increasing
o 2M cases in UKo ~2M cases in UK
o Age 55-64y– Affects 8% ♂ and 3% ♀♀
o Age 65-74yo Age 65-74y– Affects 14% ♂ and 8% ♀
Epidemiology of Stable Anginap gy g
o In 2009/10 ~45K admission → ~65K bed dayso In 2009/10 45K admission → 65K bed days
67 000 l ti PCI’o ~67,000 elective PCI’s per year
o ~50% of patients undergoing PCI are on no or suboptimal medical Rxp
o In 2009/10 ~300K angina patients attendedo In 2009/10, ~300K angina patients attended Cardiology Outpatient appointments
Myocardial Ischaemiay
o Mismatch between myocardial oxygeno Mismatch between myocardial oxygen supply and demand
o Primary reduction in blood flowo Primary reduction in blood flow
o Inability to increase blood flow to match increased metabolic demandincreased metabolic demand
Functional Anatomy of Coronary Circulation
Capillary Bed
I t di lIntramyocardial
Effect of Epicardial Stenosis on Resting Coronary Resistance and FlowCoronary Resistance and Flow
Capillary Bed
Intramyocardial
R2R1 R2=
Capillary Bed
Intramyocardialy
R1 R2>R1 R2>Gould, Lipscomb, Calvert Circulation 1975
Effect of Coronary Stenosis on Flow Response to VasodilatorsResponse to Vasodilators
Gould and Lipscomb Am Heart J 1974 Uren et al. N Engl J Med 1994
Angina PectorisAngina Pectoriso Angina pectoris is a clinical diagnosiso Angina pectoris is a clinical diagnosis
o Discomfort in the chest, jaw, shoulders, arms, or back.arms, or back.
o Provoked by exertion or emotional stress
o Relieved by rest or s.l. GTN in < 5min
I ti ti f St bl CHDInvestigation for Stable CHD
o To confirm the clinical diagnosisDemonstrate myocardial ischaemia– Demonstrate myocardial ischaemia
o To assess risk of future adverse cardiovascular eventso To assess risk of future adverse cardiovascular events– Burden of myocardial ischaemia– Anatomic severity coronary artery diseaseAnatomic severity coronary artery disease– LV function
o Choice of test dependent on clinical probability of CHD
Investigation of CHDInvestigation of CHD
Functional Anatomical
E i ECG
Non-invasive
Exercise ECGStress echo
Stress cardiac MRIPET/CT
CT coronary calcium scoreCT coronary angiogramPET/CT
Stress nuclear MPSFFRCT
CT coronary angiogram
Invasive
CFRPressure wire (FFR)
iFR Coronary angiogramIVUSOCT
Coronary angiogram
I l t i i i di tiInvolves exposure to ionising radiation
How do we diagnose CHD?gAnatomical Functional
Treatment Strategiesg
o Improve blood supplyo Improve blood supply– Revascularisation (PCI, CABG)– Vasodilators
o Reduce myocardial oxygen demando Reduce myocardial oxygen demand– HR (b blockers, Ca antagonists, If blockers)
ll t (ACE i hibit C t i t )– wall stress (ACE inhibitors, Ca antagonists)– Metabolic modifiers
o Prevent atherosclerosis progression and risk of death/MIrisk of death/MI
…a man with …a man with severe chest pain severe chest pain going down thegoing down theSpelling
mistake
going down the going down the arms: Death is arms: Death is near …near …
The Ebers Papyrus 2600 B.C.with kind permission from J.C. Kaski
Definition of MI
o Myocardial cell death arising fromo Myocardial cell death arising from interrupted blood flow to the heart
Coronary plaque rupture– Coronary plaque rupture– Coronary plaque erosion– Coronary dissection
o Mechanisms of myocardial cell death– Oncosis– Apoptosisp p
Universal Definition Acute MI
Acute MI
Acute Coronary Syndromesy yo Inflammation
– Systemic– Local
o Plaqueo Plaque– Rupture– Erosion– Erosion
Th b io Thrombosis
Hansson N Engl J Med 2005
“Man lives with atherosclerosis but dies from thrombosis”
ACSACS Didischem 1957ACSACS Didischem 1957
THROMBOSISTHROMBOSIS
70-80 % 20-30 %PLAQUE RUPTUREPLAQUE EROSION
Thrombosis - Virchow’s Triado Abnormal vessel wall (endothelial dysfunction,
inflammation atherosclerosis)inflammation, atherosclerosis)
o Abnormal blood flow (endothelial dysfunction, turbulent flow at bifurcations and stenoses, stasis)
o Abnormal blood constitutents (endothelial dysfunction hypercoagulability abnormaldysfunction, hypercoagulability, abnormal platelet function, altered fibrinolysis, metabolic, hormonal factors)hormonal factors)
Thrombosis
White Thrombuso Platelet rich
Red Thrombuso Fibrin rich, with trapped
o Common in arterial thrombosis (high
pperythrocytes
o Common in venous or pressure/turbulent circulation)B fit f ti l t l t
low pressure situations (stasis)B fit fo Benefit from antiplatelet
therapyo Benefit from
anticoagulant or anti-fibrinolytic therapyfibrinolytic therapy
Effect of Coronary Stenosis on Haemodynamics
HSSHSS
LSS OSS
Kern et al. JACC 2010
BLOODHEART
TF Circulates in Blood: Possible Cellular Sources
BLOODHEARTmyocardial
ischaemia
monocytemyocyte
TF PMNfibroblast
macrophage
AT plaqueEndothelial cellEndothelial cell
VESSEL WALL
AT plaque
SMClipid core
VESSEL WALLAdapted from Badimon JJ
Tissue Factor as a Determinant of Thrombosis
TF/VIIaTF/VIIa
XX IXIX
IXaIXaVIIIaVIIIa
IXaIXa
VaVa
XaXa ATAT
IIII
XaXa
IIaIIa
Fibrinogen → FibrinFibrinogen → Fibrin
Adapted from Adapted from WeitzWeitz JI: JI: J J ThromThrom HaemostHaemost. 2007 Jul 5 . 2007 Jul 5 SupplSuppl 1:651:65--77
PPCI for STEMI
Development of Infarction
Reperfusion Injuryp j y
Yellon & Hausenloy NEJM 2007
Post-MI LV Remodellingg
Mechanisms Underlying LV Remodelling
o Infarct thinning, elongation, expansiono LV dilatation
– reduce wall tension– maintains cardiac output
o Non-infarcted myocardiumo Non infarcted myocardium– LVH + myofilament dysfunction– Altered electromechanical couplingAltered electromechanical coupling– Myocardial fibrosis– ApoptosisApoptosis– Inflammation
Consequences of Adverse LV Remodelling
o Increased systolic wall tension/stressyo Increased MVO2o Reduced myocyte shorteningo Reduced myocyte shorteningo Increased diastolic wall tension/stresso Reduced subendocardial perfusiono Dysynchronous depolarization/contractiony yo Mitral regurgitationo Ventricular arrhythmiaso Ventricular arrhythmiaso Ventricular fibrillation
Manage Thrombotic Burden/Riskg
Acute RecurrentAcuteo Thrombectomy
D
Recurrento Oral antiplatelet drugs
A ti l to Drugs– Oral antiplatelets: Aspirin,
clopidogrel, prasugrel,
o Anticoagulants– Direct thrombin inhibition– Factor Xa inhibitorsclopidogrel, prasugrel,
ticagrelor– SC anticoagulants: LMWH,
fondaparinux
– Factor Xa inhibitors
fondaparinux– IV antiplatelets: GpIIb/IIIa
inhibitors – IV anticaogulants:
Bivalirudin,, fibrinolytics, Factor Xa inhibitorsFactor Xa inhibitors
Plaque Stabilisationq
Mechanicalo Stent
Drugso Statins (high dose)( g )o ACE inhibitors
Manage LV Remodellingg g
Non-Drug DrugsNon Drugo CRT-P/Do Progenitor cells
Drugsο β blockerso ACE inhibitorso Progenitor cells o ACE inhibitorso Angiotensin receptor
blockersblockerso Aldosterone receptor
antagonistsg
Embolism
o An obstruction in a blood vessel due to a thrombus or other foreign matter that gets stuck while travelling through thestuck while travelling through the bloodstream.A t i l (th b [ACS TIA t k ] io Arterial (thrombus [ACS, TIA, stroke], air, fat, amniotic, foreign body/material)
o Venous (thrombus [DVT, PE])
TIA/Strokeo Embolic o Haemorrhagic
– ICA plaque rupture– Intracardiac (e.g. AF, old
MI valve disease)
– Vascular malformation– Hypertension
TMI, valve disease)– Intracardiac communication
o Treatment
– Tumor– Iatrogenic
o Treatmento Treatment– Fibrinolysis– Clot extraction
o Treatment– Coil/clip aneurysm– Withdraw pro-haemorrhagic
– Antiplatelet drugs– Modify atherosclerotic risk
factors
p gmedication
– Control hypertensionfactors
– Endarterectomy, stent– Hole closure
Venous ThromboembolismDeep Vein Thrombosis
o Incidence: 1.6/1000/yr
Pulmonary Embolism
o Symptoms: Dyspnoea, chest pain, h potension shocko Aetiology:
– Trauma– Orthopaedic surgery
Malignancy
hypotension, shocko Diagnosis: clinical, ECG, D-dimer,
echo, CTPA, MRI, VQ scan, pulmonary arteriogram– Malignancy
– Autoimmune disease– Thrombophilia– Immobility
pulmonary arteriogramo Complications: death, shock,
pulmonary hypertension, RV failureo Treatment: anticoagulation,y
o Diagnosis: Clinical (Wells Score), D-Dimer, Duplex ultrasound, CT, MRI, Venography
o Complications:
o Treatment: anticoagulation, fibrinolysis, mechanolysis, IVC filter
– PE (in 50% if symptomatic DVT untreated)– Post-thrombotic syndrome (in ~45% within 1
year of symptomatic DVT’s)– Venous ulcerVenous ulcer
o Prevention– TEDS, sc LMWH/Anti-Xa
o Treatment– Anticoagulation, Fibrinolysis, Thrombectomy
Embolism - Othero Air embolism
– Iatrogenic– Decompression sickness– Trauma
o Fat embolism– Trauma
A i ti fl id b lio Amniotic fluid embolism– Pulmonary vasoconstriction, inflammation– ~1:54,000 deliveries, CFR 13-30%
Sudden CV collapse: Pulmonary HTN + RV failure > LV failure– Sudden CV collapse: Pulmonary HTN + RV failure -> LV failure– DIC– Rx: pulmonary vasodilators, FVIIa, ITU support
o Cholesterol embolism– Showers of microemboli from within plaque of large calibre artery– Plaque rupture (spontaneous, traumatic, iatrogenic)– Embolization of plaque debris (cholesterol crystals, platelets, fibrin)– Lodging of emboli in arterioles 100-200μm diam.– Foreign body inflammatory response– End-organ damage due to microvascular plugging and inflammation