The Pathology of Ischaemic Heart Disease

Ischaemic Heart Disease (IHD)

Definition

Refers to structural and functional abnormalities of the heart as a consequence of an inadequate blood supply (Most cases are due to coronary atherosclerosis)

Risk Factors for IHD

(Same as for Atherosclerosis)
Hypertension Hyperlipidaemia Cigarette smoking Diabetes mellitus Sedentary lifestyle Obesity Stress

Causes of IHD other than Atherosclerosis

Congenital anomalies of coronary arteries Arteritides (inflammatory conditions) Coronary embolism Coronary ostial stenosis Trauma Others Iatrogenic injury, dissection

Clinical Syndromes of IHD

Angina pectoris Myocardial infarction Sudden cardiac death Chronic ischaemic heart disease

Pathogenesis of IHD

Fixed coronary obstruction due to atherosclerosis with significant narrowing of lumen Secondary disruption of the plaque leading to:
Occlusive thrombosis Platelet aggregation Arterial spasm

Angina Pectoris
Definition
A clinical syndrome characterized by paroxysmal chest pain resulting from transient ischaemia, which falls short of inducing infarction (cellular necrosis)

Different clinical patterns are recognized

Angina
Pathophysiology
Atherosclerosis of coronary arteries almost invariably present No specific morphological changes present in myocardium Different clinical patterns may have correlation to pathophysiologic changes

Myocardial Infarction (MI) General

Most important form of IHD & leading cause of death in industrialized nations Difference in race (white vs blacks) is debatable Incidence increases with age Males > females (until menopause) Predisposing factors = Those of atherogenesis

Diagnosis of Acute MI

Typical symptoms ECG changes Laboratory investigations :

Hematological - ESR, WBC Biochemical - CK, AST, LD, Troponims

(Radiographic procedures)

Pathology of Myocardial Infarction

Two major morphologic types: Transmural - involving the whole
thickness of a wall

Subendocardial

Features of Transmural Infarction

Almost always occurs in the LV Extends from subendocardium to subepicardium Thrombotic occlusion of a major coronary vessel almost invariably present Distribution of infarction uniform: extent variable

Relation of Coronary Artery Lesion to Location of Infarction

LAD (40-50 %) - Anterior LV - Anterior IV septum RCA (30-40 %) - Posterior LV - Posterior IV septum LCX (15-20 %) - Lateral wall of LV

Subendocardial Infarction
Affects only inner portion of myocardium May extend beyond perfusion territory of a single coronary artery Often multifocal Stenosis of 3 vessels often present Total occlusion of large coronary artery does not play a significant role in the pathogenesis May be a result of marked fall in BP

Macroscopic Changes in MI
<12 hr. - Not visible on gross examination 12-24 hr. - Red-blue appearance 3-4 days - Area sharply defined; border more distinct 7-10 days - Bright yellow area 3 weeks - Thinning of myocardium - fibrous tissue becomes apparent 6-8 weeks - Scar tissue well established-white

Histology of MI
Necrotic myocytes Attract acute inflammatory response
- predominantly neutrophils (2-4 days) - increasing macrophages (4+ days)

Granulation tissue Fibrous tissue

Major Complications of MI
Arrhythmias Cardiogenic shock Mural thrombosis thromboembolism Cardiac rupture (external or internal) Ventricular aneurysm

Sudden Cardiac Death (SCD)

Death occurring within 1 hour of onset of cardiac symptoms Other causes besides IHD exist When due to IHD, sole abnormality is coronary atherosclerosis Mechanism of SCD attributed to a lethal arrhythmia Term NOT synonymous with early MI

CORONARY ARTERY ATHEROSCLEROSIS

Spasm Platelet aggregation

OCCLUSIVE THROMBOSIS
Myocardial O2 demand Other predisposing factors ACUTE MYOCARDIAL ISCHEMIA ACUTE MYOCARDIAL INFARCTION HEALED INFARCT ANGINA PECTORIS

SUDDEN CARDIAC DEATH

Current Therapeutic Modalities for Reperfusion

Intracoronary thrombolytic therapy - Streptokinase - Other thrombolytics Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery stenting Coronary artery bypass graft (CABG)