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CORONARY ARTERY DISEASE

epidemiology
Leading cause of death in industrialized world Same risk factors as for atherosclerosis Men more at risk than women; risk gap narrows
for post-menopausal

Over last two decades, 30% decline

topography
Epicardial not intramyocardial vessels End circulation
(with potential collaterals that may develop).

The unstable plaque


Ulceration, rupture or fissuring Hemorrhage into plaque

Fixed stenosis: stable angina


> 75 % = 1/16 flow! R4 Variables:
Myocardium:
Work Hypertrophy

O2 supply:
BP Hemoglobin

Fixed stenosis: subendocardial myocardial infarction


High-grade stenosis + Low flow or anemia
involves more than one CA territory

Fixed stenosis: subendocardial myocardial infarction


High-grade stenosis + Low flow or anemia
involves more than one CA territory

Fixed stenosis: subendocardial myocardial infarction


High-grade stenosis + Low flow or anemia
involves more than one CA territory if all three vessels are involved,

circumferential

PLAQUE DISRUPTION WITH COMPLETE CORONARY OCCLUSION:

TRANSMURAL MYOCARDIAL INARCTION

Plaque disruption with complete coronary occlusion: Transmural myocardial infarct


Smaller (50-75% stenotic) more fatty plaques prone to fissure, ulcerate or rupture Plaque disruption: thrombosis Role for plaque hemorrhage in some Complete transmural ischemia results (eventually) unless collaterals.

Classic transmural infarcts


LAD: Anteroseptal apex

Classic transmural infarcts


Right coronary: Postero-septal transmural MI
Variable right ventricular infarction

PLAQUE DISRUPTION WITH INCOMPLETE CORONARY OCCLUSION:

UNSTABLE ANGINA, SUBENDOCARDIAL INFARCT, AND SUDDEN CARDIAC DEATH

UNSTABLE ANGINA
Onset of chest pain at rest No EKG or biochemical evidence of MI Incomplete occlusion by thrombus and role for vasoconstriction Thrombus embolizes to cause micro-infarct May crescendo May announce MI in evolution

UNSTABLE ANGINA
Onset of chest pain at rest No EKG or biochemical evidence of MI Incomplete occlusion by thrombus and role for vasoconstriction Thrombus embolizes to cause micro-infarct May crescendo May announce MI in evolution

UNSTABLE ANGINA
Onset of chest pain at rest No EKG or biochemical evidence of MI Incomplete occlusion by thrombus and role for vasoconstriction Thrombus embolizes to cause micro-infarct May crescendo May announce MI in evolution

UNSTABLE ANGINA
Onset of chest pain at rest No EKG or biochemical evidence of MI Incomplete occlusion by thrombus and role for vasoconstriction Thrombus embolizes to cause micro-infarct May crescendo May announce MI in evolution

UNSTABLE ANGINA
Onset of chest pain at rest No EKG or biochemical evidence of MI Incomplete occlusion by thrombus and role for vasoconstriction Thrombus embolizes to cause micro-infarct May crescendo May announce MI in evolution

UNSTABLE ANGINA
Onset of chest pain at rest No EKG or biochemical evidence of MI Incomplete occlusion by thrombus and role for vasoconstriction Thrombus embolizes to cause micro-infarct May crescendo May announce MI in evolution

SUDDEN CARDIAC DEATH


Patients autopsied may have disrupted plaque but usually no occluding thrombus Patients who survive do not always develop infarcts Micro-emboli occasionally found in small vessels at autopsy Local ischemia can give electrical instability and arrhythmia

The Pathology of Myocardial Infarction


Macroscopic Findings

The Pathology of Myocardial Infarction


Macroscopic Findings

The Pathology of Myocardial Infarction


Macroscopic Findings

The Pathology of Myocardial Infarction


Macroscopic Findings

The Pathology of Myocardial Infarction


Microscopic findings

The Pathology of Myocardial Infarction


Microscopic Findings

The Pathology of Myocardial Infarction


Microscopic Findings

Subendocardial vs. Transmural Myocardial Infarction

Subendocardial vs. Transmural Myocardial Infarction


Inner 1/3 or 1/2 Extend past territory of one artery May be circumferential Related to incomplete occlusion +/- low flow Non-Q wave Distribution of one artery Related to complete occlusion Q-wave

Infarcts and Reperfusion

Ischemic Cardiomyopathy
Chronic ischemic heart disease with or without previous MI Diffuse patchy scarring and high-grade coronary stenosis Some hypertrophy possible Subendocardial myocytolysis Heart failure

Complications of Myocardial Infarction


Heart failure and cardiogenic shock
> 40% loss of myocardium = shock

Arrhythmia and conduction abnormalities


Ventricular tachyarrhythmias and asystole

Ventricular rupture Mural thrombus and embolism

Complications of Myocardial Infarction


Heart failure and cardiogenic shock
> 40% loss of myocardium = shock

Arrhythmia and conduction abnormalities


Ventricular tachyarrhythmias and asystole

Ventricular rupture
Cardiac tamponade

Mural thrombus and embolism

Coronary Artery Disease