LECTURE 1 LECTURE 1

DR ZAHOOR ALI SHAIKHDR ZAHOOR ALI SHAIKH

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CORONARY ARTERY DISEASE (CAD)

What is Coronary Artery Disease?

CAD is heart disease due to impaired coronary blood flow.

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CORONARY ARTERY DISEASE (CAD) CAD can cause

- Myocardial ischemia or Angina called

Ischemic heart disease (IHD)

- Myocardial infarction or Heart attack

- Conduction effect

- Heart failure

- Sudden death

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First we will discuss normal coronary circulation and factors affecting it.

Then we will discuss Ischemic heart disease.

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CORONARY CIRCULATION Coronary vessels travel across the

surface of heart under epicardium. Heart is supplied by TWO CORONARY

arteries:

1- Left coronary artery---(LCA)

2- Right coronary artery---(RCA) These coronary arteries arise at the root

of the aorta.

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Coronary artery & their branches

Left coronary artery is about 3.5cm and then divides into

LCA---- -Lt Anterior Descending (LAD)

-Circumflex Artery

Right Coronary Artery

RCA ---- -Marginal Artery

-Posterior descending branch

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LEFT CORONARY ARTERY

LAD--- Supplies anterior and apical parts of heart ,and Anterior 2/3rd of interventricular septum.

Circumflex branch-- supplies the lateral and posterior surface of heart.

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Right coronary artery(RCA) supplies: Right ventricle Part of interventricular septum (posterior

1/3rd) Inferior part of left ventricle SA Node AV Node

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Diagram of coronary circulation

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Blood flow to Heart during Systole & Diastole

During systole when heart muscle contracts it compresses the coronary arteries therefore blood flow is less to the left ventricle during systole and more during diastole.

To the subendocardial portion of Left ventricle it occurs only during diastole

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Coronary blood flow to the right side is not much affected during systole.

Reason---Pressure difference between aorta and right ventricle is greater during systole .

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CORONARY BLOOD FLOW DURING SYSTOLE AND DIASTOLE

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Effect of Tachycardia on coronary blood flow:

During increased heart rate, period of diastole is shorter therefore coronary blood flow is reduced to heart during tachycardia.

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As we know blood flow to subendocardial surface of left ventricle during systole is not there, therefore, this region is prone to ischemic damage and most common site of Myocardial infarction.

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Other causes of decreased blood flow to left ventricle

1-Aortic stenosis

Reason---As left ventricle pressure is very high during systole, therefore, it compresses the coronary arteries more.

2-When aortic diastolic pressure is low, coronary blood flow is decreased

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CORONARY BLOOD FLOW Coronary blood flow in Humans at rest is

about 225-250 ml/minute, about 5% of cardiac output.

At rest, the heart extracts 60-70% of oxygen from each unit of blood delivered to heart [other tissue extract only 25% of O2.

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CORONARY BLOOD FLOWWhy heart is extracting 60-70% of O2?

Because heart muscle has more mitochondria, up to 40% of cell is occupied by mitochondria, which generate energy for contraction by aerobic metabolism, therefore, heart needs O2.

When more oxygen is needed e.g. exercise, O2 can be increased to heart only by increasing blood flow.

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Factors Affecting Blood Flow to CORONARY ARTERIES

-Pressure in aorta

-Chemical factors

-Neural factors

NOTE—Coronary blood flow shows considerable Autoregulation.

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Chemical factors affecting Coronary blood flow

Chemical factors causing Coronary vasodilatation (Increased coronary blood flow)-Lack of oxygen-Increased local concentration of Co2-Increased local concentration of H+ ion-Increased local concentration of k + ion-Increased local concentration of Lactate,

Prostaglandin, Adenosine, Adenine nucleotides.

NOTE – Adenosine, which is formed from ATP during cardiac metabolic activity, causes coronary vasodilatation.

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Neural factors affecting Coronary Blood Flow

1. -Effect of Sympathetic stimulation2. -Effect of Parasympathetic stimulation

Sympathetic stimulationCoronary arteries have Alpha Adrenergic receptors which mediate

vasoconstrictionBeta Adrenergic receptors which mediate

vasodilatation

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Sympathetic stimulation------Cont Effect of sympathetic stimulation in intact

body---Epinephrine and Norepinephrine causes Coronary VASODILATATION.

HOW ? But the Direct effect of sympathetic on

Coronary arteries is VASOCOSTRICTION.

WHY ?

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Effect of Parasympathetic stimulation -Vagus nerve stimulation (Parasympathetic)

causes coronary vasodilatation

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NUTRIENT SUPPLY TO HEART

Heart uses primarily free fatty acids and to lesser extent glucose and lactate for metabolism.

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CORONARY ARTERY HEART DISEASE

ISCHEMIC HEART DISEASE (IHD) (ANGINA PECTORIS)

MYOCARDIAL INFARCTION

ANGINA PECTORIS:THERE IS REDUCED CORONARY ARTERY

BLOOD FLOW DUE TO ATHEROSCLEROSIS (CHOLESTROL DEPOSITION SUBENDOTHELIAL)

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CAUSES OF IHD:

CIGARETTE SMOKINGHYPERTENSIONDIABETES MELLITUSINCREASED LIPIDS ( CHOLESTROL)OTHER FACTORS: LACK OF EXERCISE,

ANXIETY etc.

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IHD:IHD IS USED TO DESCRIBE DISCOMFORT IN

THE CHEST DUE TO DECREASED CORONARY BLOOD FLOW (TRANSIENT MYOCARDIAL ISCHEMIA).

PATIENT COMPLAINS OF TIGHTNESS OR PAIN IN THE MIDDLE OF CHEST (RETROSTERNAL) FOR FEW MINUTES. PAIN OFTEN RADIATES TO INNER SIDE OF LEFT ARM.

PAIN IS PRECIPETED BY EFFORT AND RELIEVED BY REST.

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MYOCARDIAL INFARCTION (MI):

IT IS DUE TO OBSTRUCTION TO THE CORONARY BLOOD FLOW, ATLEAST 75 % OF LUMEN OF CORONARY ARTERY IS BLOCKED BY THROMBUS.

MI IS THE COMMEN CAUSE OF DEATH.

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Applied Aspect

THE C A D.

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Electrocardiographic changes duringexercise test. Upper trace – significant horizontal ST segment depression during exercise.

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STEMI CHANGES

INVESTIGATIONS:ECGCARDIAC ENZYMES e.g. CK, LDH, TROPONIN etc.ECHOCARDIOGRAPHYTREADMILL EXERCISE TESTTHALLIUM STRESS TESTCORONARY ANGIOGRAPHY

NOTE: ○ ECG CHANGES IN IHD:

ST DEPRESSION OCCURS IN ECG IN RESPECTIVE LEADS

○ ECG CHANGES IN MI:ST ELEVATION OCCURS IN ECG IN RESPECTIVE LEADS

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TREATMENT:CORONARY DILATORS E.g. NITRATESBETA-BLOCKERSANGIOPLASTY (DILATE AREA OF

CONSTRICTION)STENTBYPASS SURGERY

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Percutaneous transluminal coronary angioplasty (PTCA). (a) Coronary angiography demonstrates a severe stenosis in the proximal left anterior descending artery. (b) During PTCA a soft guidewire is passed across the stenosis and then a balloon is expanded that dilates the stenosis. (c) Post-PTC

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An intracoronary stent.

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THANK YOUTHANK YOU

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