Prof. S.M. Andreychyn

1. Atherosclerosis. IHD. Classification WHO. Angina pectoris. Classification.Emergency care. Cardiopulmonary resuscitation. Prof. S.M. Andreychyn

2. DEFINITION IHD - synonims – coronary disease, coronary insufficiency – is severe chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart's blood vessels).

3. RISK FACTORS Smoking alcohol abuse high arterial pressure Dislipidemia Diabetes mellitus Obesity Excessive consumption of animal fats thrombogenic factors Lack of physical activity

4. Ethiology. Smoking Dyslipidemia Arterial hypertension Diabetes mellitus Obesity Dietary factors Thrombogenic factors Lack of physical activity Alcohol abuse

5. Causes of IHD 85 % - stenotic atherosclerosis of coronary arteries 10 % - spasm of coronary arteries 5 % - transitory thrombocytes aggregates 100 % - combination of these factors Morbidity in males is 4 times higher than in females

7. Pathogenesis

10. Atherosclerosis

11. Atherosclerosis Distributed chronic disease characterized by specific lesions of arteries of elastic and muscular types as growths in the walls of connective tissue with lipid infiltration of the inner shell. This leads to organ and total circulatory disorders.

12. Complaints Complaints and clinical manifestations are determined by the localization of atherosclerotic plaques, their vulnerability and the degree of occlusion of the vascular lumen. Examples of localization of the pathological process: *in the coronary arteries - coronary heart disease *in the vessels of the lower extremities - atherosclerosis *vessels of the brain - the cerebral circulation disorders.

13. Atherosclerosis is a pathologic basis of coronary heart disease, brain and peripheral arteries diseases. These diseases cause over 60% mortality from all diseases in developed countries.

14. Classification 1.Preclinical, hidden period: nervous, vasomotor and metabolic disorders. 2. Period of clinical manifestations *The first stage (ischemic) - vasoconstriction, leading to disruption of trophic and dystrophic changes in the relevant organs. *The second stage (thrombo necrotic) – micro- or macrofocal necroses with vessel thrombosis without them. *The third stage (sclerotic or fibrotic) - development of fibrous, cicatricial changes in the organs with atrophy of the parenchyma.

15. Atherosclerosis of cerebral vessels

16. Functional research methods 1. Electrocardiography using pharmacological and exercise testing to detect coronary artery disease 2. Echocardiography (left ventricular hypertrophy). 3. Visualizing the walls of arteries and differentiation of elements of atherosclerotic plaque by MRI. 4. Determination of coronary calcificates using computed tomography.

17. Echocardiography

18. The accumulation of cholesterol in the vascular wall - atherosclerotic plaque

19. Laboratory diagnostic Total cholesterol less than 5 mmol / l LDL cholesterol less than 3 mmol / l HDL Cholesterol higher than 1 mmol / l Triglycerides less than 2 mmol / l

20. Treatment Diet Changing lifestyles Statins - drugs for the correction of lipid metabolism. Fibrates - prevent the absorption of lipids in the intestine.

21. Clinical forms of IHD 1. Sudden coronary death or heart arrest (HA) 2. Angina pectoris (AP) 2.1 Stable angina at exertion. 2.1.1 Stable angina at exertion( functional class should be determined). 2.1.2 Stable angina at exertionin angiographically intact vessels (coronary syndrome X).

22. 2.2. Angiospastic angina (angina in rest, spontaneous, variant, Prinzmetals’ angina) 2.3. Unstable angina. 2.3.1. Primary angina. 2.3.2. Progressive angina. 3. MYOCARDIAL INFARCTION (МI) 4. CARDIOSCLEROSIS (postinfarctional, focal and diffuse) 5. MYOCARDIAL ASCHEMIA WITHOUT PAIN 6. CARDIAC RRHYTHM DISORDERS (form) 7. HEART FAILURE (stage, functional class)

23. Angina pectoris Angina is attack of retrosternal pressing pain or chest dyscomfortwhich occures in physical load or emotional strain and is caused by myocardial ischemia.

24. Provoking factors: • physical load; • Emotional strain; • cold; • overeating; • smoking; Factors which decrease pain: • Refuse of physical load; • Nitroglycerin/ • Patient try to stay or lie down in attack.

27. Stable angina at exertion Occurs in the same provoking factors, is often follows with the same complains and changes on ECG.

28. AP functional classes І FC – attacks occur in a whery high load 1 – 2 times a year. Coronary arteries lumen is narrowed not more than on 50 %. ІІ FC – attacks occur in walking on the plane surface on the diastance more than 500м, in going more than on 1 floorupstairs 2 – 3 times a week. Coronary arteries lumen is narrowed not more than on 75 %.

29. ІІІ FC – attacks occur in walking on the plane surface on the diastance 200 – 300 м, in going 1 floorupstairs. Postinfarctional angina. Coronary arteries lumen is narrowed more than on 75%. ІVFC – attacks occur in walking on the plane surface on the diastance less than on 100 м, in rest. Combination of coronary and myocardial insufficiency. Complete obturation of coronary arteries.

30. Clinical pattern The major sign of stenocardia is attack-like pain in the area of heart. It has squeezing, cutting or burning character with localization behind a breastbone, irradiates in a left arm (left shoulder-blade, left half of neck, lower jaw, sometimes – in a right shoulder or shoulder-blade). Duration of pain of 5-10 min (more frequently – 2-5 min).

36. Coronary syndrome X This is a stable angina at exertion when small coronary arteries are affected. Clinical pattern is the same as for stable angina but coronarography does not show obturation of coronary arteries.

37. Angiospastic angina Caused by spasm of coronal arteries. Arises up in young persons, mainly at night, in rest, when tone of vagus nerve prevails. Duration of attack till 30 min, during this time ECG shows changes typical for MI (depression of ST segment) which disappear after stopping of attack or application of spasmolysants. Nitrates are uneffective with the purpose of removal of attacks.

38. Unstable angina

39. Acute coronary syndrome This is a result of myocardial ischemia caused by thrombosis of coronaty artery and its complete occlusion. The syndrome includes: 1. Unstable angina pectoris. Non-Q myocardial infarction. 3. Q- myocardial infarction.

40. Unstable angina pectoris At a stenocardia which arose up first, the attacks of pain are observed during 28 days for persons, which did not have clinical signs of stenocardia before. Usually this is angina at exertion. Progressing angina is the state, at which duration, intensity and frequency of anginal attacks, grow in a dynamics, and the usual dose of medications which take off an attack becomes insufficient, that requires its permanent increase.

41. Characteristic for progressing stenocardia is pressing pain behind the sternum, which periodically calms down and grows, is not removed by nitrates, is accompanied with swweating, dyspnea, arrhythmia, fear of death. The episodes of attacks of anginal pain become more frequent, and periods between attacks shorten. Every next attack is heavier, than previous. Nitrates (nitroglycerine, Nitrosorbidum), which removed the attacks of anginal pain before, are uneffective, although a patient uses considerably increased their amount.

42. Associated manifestations Pain can arise up not obviously due to emotional or physical loading, but also in rest. Sometimes only narcotic facilities remove him. On a background a stenocardia there can be an attack of sharp left-ventricular insufficiency with dyspnea, dry cough, bubbling in the chest.

43. Diagnostics of angina pectoris functional tests: • - exposure to cold; • - test with hyperwentilation; tests with dynamic physical load: • а) veloergometry; • б) tredmile test; emotional stress-test; pharmacological tests; • а) test with dityridamole; • б) test with isadrine; • в) test with ergometrine; transesophageat atrial electrostimulation; daily ECG-mpnitoring coronary angiography.

44. Tests with physical load

46. Laboratory examinations Complete blood count – 1 time a year Byochemical blood serum study (lipid spectre, cholesterol - 1 time a year) ЕCG and functional tests – 2-3 times a year in stable angina depending on functional class.

47. Resuscitation measures

48. Treatment Healthy life stile. Correction of risk factors, limitation of carbonhydratess and saturated fats in diet. Employment. Psychprrophylaxis. Medication (nitrates, other antianginal preparations on a sedate agents) depending on a functional class and concomitant diseases. Sanatorium-resort treatment.

49. Thank you!