Ischemic Heart

Disease
Coronary artery disease

• Risk factors for coronary artery disease

• Pathogenesis
• Clinical presentation
• Treatment overview
 Risk Factors for Coronary artery
disease

Non-modifiable Modifiable
 Age  Cigarette smoking
 Family history  Diabetes mellitus
 Sex  Hyperlipidemia
 Hypertension
Other less important risk factors

• Obesity
• Physical inactivity
• Stress ( type A personality)
• Postmenopausal estrogen deficiency
• Alcohol
Pathogenesis of coronary artery
disease
Atherosclerosis

The underlying pathogenesis of

coronary arterial disease is
atherosclerosis
 Pathogenesis of myocardial
ischemia
Coronary artery atherosclerosis

Most of the patients with coronary artery disease has coronary

atherosclerosis which cause obstruction to blood flow
Effect of atherosclerosis

• Most have one or more lesions causing at least 75% reduction of the
cross-sectional area of coronary arteries

• Coronary Artery Disease = insufficient flow of blood through

coronary arteries
 Presentation of coronary heart disease

Asymptomatic Chronic stable Acute coronary Heart failure

angina syndrome (ACS) Death

Unstable angina
Non ST elevation MI
ST elevation MI

(MI = Myocardial Infarction)

 Presentation of coronary heart disease

Asymptomatic Chronic stable Acute coronary Heart failure

angina syndrome (ACS) Death

Unstable angina
Non ST elevation MI
ST elevation MI

(MI = Myocardial Infarction)

Asymptomatic

• The degree of obstruction sometimes do not correlate with

symptoms.
• Patient may be still asymptomatic despite high degree of obstruction
• Patient may also loss the sensation of pain as a result of neuropathy
especially with diabetes mellitus
 Presentation of coronary heart disease

Asymptomatic Chronic stable Acute coronary Heart failure

angina syndrome (ACS) Death

Unstable angina
Non ST elevation MI
ST elevation MI

(MI = Myocardial Infarction)

Sudden death

• May be the first manifestation in 25% of patients

• 20% of patients with AMI die before reaching hospital
• Most of these death are caused by ventricular
fibrillation
 Presentation of coronary heart disease

Asymptomatic Chronic stable Acute coronary Heart failure

angina syndrome (ACS) Death

Unstable angina
Non ST elevation MI
ST elevation MI

(MI = Myocardial Infarction)

Angina Pectoris

• Imbalance of oxygen supply and demand

• Decreased blood flow to myocardium
• Results in chest pain described as constricting,
squeezing, choking, or knifelike

• Switch to anerobic metabolism

• Lactic acid build up
• Kinins, histamine, other substances released
• Nerve fibers are stimulated
Typical Angina
Typical Angina
Typical Angina
Types of angina

Angina

Prinzmetal
Unstable
Stable angina variant
angina
angina
Stable angina

• Also called exertional angina

• The lumen of coronary artery is narrowed and hard; thus, dilation in
response to increased demand is impossible
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
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.
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
 Presentation of coronary heart disease

Asymptomatic Chronic stable Acute coronary Heart failure

angina syndrome (ACS) Death

Unstable angina
Non ST elevation MI
ST elevation MI

(MI = Myocardial Infarction)

Acute coronary syndrome

Acute
Coronary
Syndrome

Non-ST
Acute
Unstable Elevation
Myocardial
angina Myocardial
infarct
Infarct
 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

Cardiac enzymes

Myoglobulin
Troponin
Creatinine kinase (MB)
ALT
Lactate dehydrogenase
Clinical features of Acute Myocardial
Infarction

Angina
Prolonged
Not relieved by usual dose of nitrates
Sweating
Nausea and vomiting
Palpitation
Dyspnea
Sudden death
Non ST elevation MI

• Typical chest pain

• Raised cardiac enzymes
• NO ST elevation in ECG
• But may have other ECG changes
Unstable angina

• Chest pain
• NO cardiac enzyme changes
• NO ST elevation in ECG
Lifestyle modifications

Smoking
Diabetes
Male
Hypertension
Obesity
Lack of exercise
Stress

End of Phase II 11.8.09

Coronary bypass surgery
 Development of atherosclerosis

Smoking

Blood Brain attack

pressure
Atherosclerosis Thrombosis Heart attack
Cholesterol
Other
Diabetes vascular
mellitus

Other
factors
 Acyanotic Congenital Heart Defects

Pink Baby (L  R shunt)

 L  R shunts cause CHF and pulmonary hypertension.

 This leads to RV enlargement, RV failure
 These babies present with CHF and respiratory distress.
 They are not typically cyanotic
 Examples: Patent Ductus Arteriosus (PDA)
Ventricular Septal Defect (VSD)
Atrial Septal Defect (ASD)
Coarctation of the Aorta
Cyanotic Congenital Heart Disease

Blue Baby (R  L shunt)

 R  L shunts cause hypoxia and central cyanosis.
 Venous blood is shunted from the R to the L side of the
heart w/o passing through the lungs to be oxygenated
 Unoxygenated blood circulates in arteries  cyanosis
 Examples:
Tetralogy of Fallot (TOF)
Transposition of the Great Arteries (TGA)
Truncus Arteriosus (TA)
Tricuspid Atresia
End of Phase II 11.8.09