Coronary Artery Disease and Acute Coronary Syndrome
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Transcript of Coronary Artery Disease and Acute Coronary Syndrome
Coronary Artery Disease and Acute Coronary Syndrome
Coronary Artery Disease and Acute Coronary Syndrome
Description
• Coronary Artery Disease (CAD)– A type of blood vessel disorder that is
included in the general category of atherosclerosis
Description
• Atherosclerosis
– Can occur in any artery in the body
– Atheromas (fatty deposits)
• Preference for the coronary arteries
• Atherosclerosis
– Can occur in any artery in the body
– Atheromas (fatty deposits)
• Preference for the coronary arteries
Description
• Atherosclerosis
– Terms to describe the disease process:
• Arteriosclerotic heart disease (ASHD)
• Cardiovascular heart disease (CHD)
• Ischemic heart disease (IHD)
• CAD
• Atherosclerosis
– Terms to describe the disease process:
• Arteriosclerotic heart disease (ASHD)
• Cardiovascular heart disease (CHD)
• Ischemic heart disease (IHD)
• CAD
Description
• Cardiovascular diseases are the major cause of death in the US and Canada
• Heart attacks are still the leading cause of all cardiovascular disease deaths and deaths in general
• Cardiovascular diseases are the major cause of death in the US and Canada
• Heart attacks are still the leading cause of all cardiovascular disease deaths and deaths in general
Etiology and Pathophysiology
• Atherosclerosis is the major cause of CAD
– Characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery
• Atherosclerosis is the major cause of CAD
– Characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery
Etiology and Pathophysiology
• Endothelial lining altered as a result of chemical injuries
– Hyperlipidemia
– Hypertension
• Endothelial lining altered as a result of chemical injuries
– Hyperlipidemia
– Hypertension
Etiology and Pathophysiology
• Bacteria and/or viruses may have role in damaging endothelium by causing local inflammation
• C-reactive protein (CRP)– Nonspecific marker of inflammation– Increased in many patients with CAD– Chronic exposure to CRP triggers the
rupture of plaques
• Bacteria and/or viruses may have role in damaging endothelium by causing local inflammation
• C-reactive protein (CRP)– Nonspecific marker of inflammation– Increased in many patients with CAD– Chronic exposure to CRP triggers the
rupture of plaques
Etiology and Pathophysiology
• Endothelial alteration – Platelets are activated – Growth factor stimulates smooth
muscle proliferation– Cell proliferation entraps lipids, which
calcify over time and form an irritant to the endothelium on which platelets adhere and aggregate
• Endothelial alteration – Platelets are activated – Growth factor stimulates smooth
muscle proliferation– Cell proliferation entraps lipids, which
calcify over time and form an irritant to the endothelium on which platelets adhere and aggregate
Etiology and Pathophysiology
• Endothelial alteration – Thrombin is generated
– Fibrin formation and thrombi occur
• Endothelial alteration – Thrombin is generated
– Fibrin formation and thrombi occur
Response to Endothelial Injury
Fig. 33-3
Stages of Development in Atherosclerosis
Fig. 33-4
Etiology and PathophysiologyCollateral Circulation
• Analogous to “detours” around atherosclerotic plaques
• Occur normally in coronary circulation• But collaterals increase in the presence of
chronic ischemia• When occlusion occurs slowly over a long
period, there is a greater chance of adequate collateral circulation developing
• Analogous to “detours” around atherosclerotic plaques
• Occur normally in coronary circulation• But collaterals increase in the presence of
chronic ischemia• When occlusion occurs slowly over a long
period, there is a greater chance of adequate collateral circulation developing
Collateral Circulation
Fig. 33-5
Risk Factors for Coronary Artery Disease
• Risk factors can be divided:
– Unmodifiable risk factors
– Modifiable risk factors
• Risk factors can be divided:
– Unmodifiable risk factors
– Modifiable risk factors
Risk Factors for Coronary Artery Disease
• Unmodifiable risk factors:
– Age
– Gender
– Ethnicity
– Genetic predisposition
• Unmodifiable risk factors:
– Age
– Gender
– Ethnicity
– Genetic predisposition
Risk Factors for Coronary Artery Disease
• Modifiable risk factors:– Elevated serum lipids– Hypertension– Smoking– Obesity– Physical inactivity– Diabetes mellitus– Stressful lifestyle
• Modifiable risk factors:– Elevated serum lipids– Hypertension– Smoking– Obesity– Physical inactivity– Diabetes mellitus– Stressful lifestyle
Risk Factors for Coronary Artery Disease
• Health Promotion– Identification of high-risk persons– Management of high-risk persons
• Risk factor modification
– Physical fitness– Health education in schools– Nutrition (weight control, ↓ fat, ↓ chol intake)
– Cholesterol-lowering medications
• Health Promotion– Identification of high-risk persons– Management of high-risk persons
• Risk factor modification
– Physical fitness– Health education in schools– Nutrition (weight control, ↓ fat, ↓ chol intake)
– Cholesterol-lowering medications
Types of Angina
• Results when the lack of oxygen supply is temporary and reversible
• Types of Angina– Stable Angina– Prinzmetal Angina– Unstable Angina
Stable Angina Pectoris
• Chest pain occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms
• Can be controlled with medications on an outpatient basis
• Pain usually lasts 3 to 5 minutes– Subsides when the precipitating factor is
relieved– Pain at rest is unusual
• Chest pain occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms
• Can be controlled with medications on an outpatient basis
• Pain usually lasts 3 to 5 minutes– Subsides when the precipitating factor is
relieved– Pain at rest is unusual
Silent Ischemia
Prinzmetal’s Angina
• Occurs at rest usually d/t spasm of major coronary artery
• Spasm may occur in the absence of CAD
• Occurs at rest usually d/t spasm of major coronary artery
• Spasm may occur in the absence of CAD
Unstable Angina
• Angina that is:– New in onset– Occurs at rest– Has a worsening pattern– Unpredictable – Considered to be an acute coronary
syndrome– Associated with deterioration of a once stable
atherosclerotic plaque
• Angina that is:– New in onset– Occurs at rest– Has a worsening pattern– Unpredictable – Considered to be an acute coronary
syndrome– Associated with deterioration of a once stable
atherosclerotic plaque
Clinical Manifestations Angina
• Chest pain or discomfort (d/t ischemia)– A strange feeling, pressure, or ache in the
chest– Constrictive, squeezing, heaving, choking, or
suffocating sensation– Indigestion, burning
• Chest pain or discomfort (d/t ischemia)– A strange feeling, pressure, or ache in the
chest– Constrictive, squeezing, heaving, choking, or
suffocating sensation– Indigestion, burning
However
• Up to 80% of patients with myocardial ischemia are asymptomatic
• Associated with diabetes mellitus and hypertension
Location of Chest Pain
Fig. 33-12
Diagnostic StudiesAngina
• ECG
• Coronary angiography
• Cardiac markers (CK MB, Troponin)
• Treadmill exercise testing (stress test)
• Serum lipid levels
• C-reactive protein (CRP)
• Nuclear imaging
• ECG
• Coronary angiography
• Cardiac markers (CK MB, Troponin)
• Treadmill exercise testing (stress test)
• Serum lipid levels
• C-reactive protein (CRP)
• Nuclear imaging
Collaborative CareAngina
• Treatment for stable angina: oxygen demand and/or oxygen
supply
– Nitrate therapy
– Stent placement
• Treatment for stable angina: oxygen demand and/or oxygen
supply
– Nitrate therapy
– Stent placement
Collaborative CareAngina
• Treatment for stable angina:
– Percutaneous coronary intervention
– Atherectomy
– Laser angioplasty
– Myocardial revascularization (CABG)
• Treatment for stable angina:
– Percutaneous coronary intervention
– Atherectomy
– Laser angioplasty
– Myocardial revascularization (CABG)
Collaborative CareAngina
• Drug Therapy
– Antiplatelet aggregation therapy
• Aspirin: drug of choice (for MI prevention)
• First line of treatment for angina
• Drug Therapy
– Antiplatelet aggregation therapy
• Aspirin: drug of choice (for MI prevention)
• First line of treatment for angina
Collaborative CareAngina
• Drug Therapy
– Nitrates
• 1st line therapy for treatment of acute anginal symptoms
• Dilation of vessels
• Drug Therapy
– Nitrates
• 1st line therapy for treatment of acute anginal symptoms
• Dilation of vessels
Collaborative CareAngina
• Drug Therapy -Adrenergic blockers
– Calcium channel blockers
• Drug Therapy -Adrenergic blockers
– Calcium channel blockers
Collaborative CareAngina
• Percutaneous coronary intervention
– Surgical intervention alternative
– Performed with local anesthesia
– Ambulatory 24 hours after the procedure
• Percutaneous coronary intervention
– Surgical intervention alternative
– Performed with local anesthesia
– Ambulatory 24 hours after the procedure
Collaborative CareAngina
• Stent placement
– Used to treat abrupt or threatened abrupt closure and restenosis following PCI
• Stent placement
– Used to treat abrupt or threatened abrupt closure and restenosis following PCI
Collaborative CareAngina
• Atherectomy
– The plaque is shaved off using a type of rotational blade
– Decreases the incidence of abrupt closure as compared with PCI
• Atherectomy
– The plaque is shaved off using a type of rotational blade
– Decreases the incidence of abrupt closure as compared with PCI
Collaborative CareAngina
• Laser angioplasty
– Performed with a catheter containing fibers that carry laser energy
– Used to precisely dissolve the blockage
• Laser angioplasty
– Performed with a catheter containing fibers that carry laser energy
– Used to precisely dissolve the blockage
Collaborative CareAngina
• Myocardial revascularization (CABG)
– Primary surgical treatment for CAD
– Patient with CAD who has failed medical management or has advanced disease is considered a candidate
• Myocardial revascularization (CABG)
– Primary surgical treatment for CAD
– Patient with CAD who has failed medical management or has advanced disease is considered a candidate
Clinical Manifestations Myocardial Infarction
• Pain
– Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration
• The hallmark of an MI
• Pain
– Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration
• The hallmark of an MI
Clinical Manifestations
• Acute Coronary Syndrome (ACS)
– Develops when the oxygen supply is prolonged and not immediately reversible
• Acute Coronary Syndrome (ACS)
– Develops when the oxygen supply is prolonged and not immediately reversible
Clinical Manifestations
• ACS encompasses:
– Unstable angina
– Myocardial infarction (MI)
• ACS encompasses:
– Unstable angina
– Myocardial infarction (MI)
Relationships Among CAD, Stable Angina, and MI
Fig. 33-8