Coronary Artery Disease and Acute Coronary Syndrome

1. Coronary Artery Disease and Acute Coronary Syndrome

2. The Heart as a Pump • The heart is a hollow muscular organ about the same size as your fist. • It is a 2 sided pump, with a muscular wall called the septum separating the right and left sides

3. The Coronary Arteries • As a muscle the heart needs oxygen and nutrients to work • The heart muscle has its own blood supply through the coronary arteries • Women’s coronary arteries tend to be smaller

4. Description • Coronary Artery Disease (CAD) • A type of blood vessel disorder that is included in the general category of atherosclerosis

5. Description • Atherosclerosis • Can occur in any artery in the body • Atheromas (fatty deposits) • Preference for the coronary arteries

6. Description • Atherosclerosis • Terms to describe the disease process: • Arteriosclerotic heart disease (ASHD) • Cardiovascular heart disease (CHD) • Ischemic heart disease (IHD) • CAD

7. Description • Cardiovascular diseases are the major cause of death in the US and Canada • Heart attacks are still the leading cause of all cardiovascular disease deaths and deaths in general

8. Etiology and Pathophysiology • Atherosclerosis is the major cause of CAD • Characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery

9. Process of Coronary Artery Disease - Atherosclerosis • Over time ….a series of events within the artery • A fatty streak (permanent)– can start in infancy & young children • Fatty – ( lipid) deposits throughout the years • Narrowing and impaired blood flow occurs with the gradual occlusion as plaque thickens and blood clots form

10. Etiology and Pathophysiology • Endothelial lining altered as a result of chemical injuries • Hyperlipidemia • Hypertension

11. Etiology and Pathophysiology • Bacteria and/or viruses may have role in damaging endothelium by causing local inflammation • C-reactive protein (CRP) • Nonspecific marker of inflammation • Increased in many patients with CAD • Chronic exposure to CRP triggers the rupture of plaques

12. Etiology and Pathophysiology • Endothelial alteration  • Platelets are activated • Growth factor stimulates smooth muscle proliferation • Cell proliferation entraps lipids, which calcify over time and form an irritant to the endothelium on which platelets adhere and aggregate

13. Etiology and Pathophysiology • Endothelial alteration  • Thrombin is generated • Fibrin formation and thrombi occur

14. Response to Endothelial Injury Fig. 33-3

15. Stages of Development in Atherosclerosis Fig. 33-4

16. Etiology and PathophysiologyCollateral Circulation • Analogous to “detours” around atherosclerotic plaques • Occur normally in coronary circulation • But collaterals increase in the presence of chronic ischemia • When occlusion occurs slowly over a long period, there is a greater chance of adequate collateral circulation developing

17. Collateral Circulation Fig. 33-5

18. Risk Factors for Coronary Artery Disease • Risk factors can be divided: • Unmodifiable risk factors • Modifiable risk factors

19. Risk Factors for Coronary Artery Disease • Unmodifiable risk factors: • Age • Gender • Ethnicity • Genetic predisposition

20. Risk Factors for Coronary Artery Disease • Modifiable risk factors: • Elevated serum lipids • Hypertension • Smoking • Obesity • Physical inactivity • Diabetes mellitus • Stressful lifestyle

21. Diabetes Treatment • Prescribed Meal Plan (sit down with a Dietitian) • Home Blood Sugar monitoring • Regular exercise – at least 150 mins./wkly • ? Medications – pills or Insulin or both • Ongoing Education- Diabetes classes • Support – family and friends • Physician follow-up or Specialist referral A person with Diabetes is considered high risk like someone who has already had a heart attack!

22. Stress - “We do not laugh because we’re happy – we’re happy because we laugh”William James • Stress may not be the main cause of disease ……. but, managing stress helps us; • maintain health • deal with health problems. Anger, anxiety and depression are major emotions that need to be dealt with for a healthy heart “75% of all good health is under our control!”

23. Risk Factors for Coronary Artery Disease • Health Promotion • Identification of high-risk persons • Management of high-risk persons • Risk factor modification • Physical fitness • Health education in schools • Nutrition (weight control, ↓ fat, ↓ chol intake) • Cholesterol-lowering medications

24. Types of Angina • Results when the lack of oxygen supply is temporary and reversible • Types of Angina • Stable Angina • Prinzmetal Angina • Unstable Angina

25. Coronary Artery

26. Stable Angina Pectoris • Chest pain occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms • Can be controlled with medications on an outpatient basis • Pain usually lasts 3 to 5 minutes • Subsides when the precipitating factor is relieved • Pain at rest is unusual

27. Silent Ischemia • 80 % of patients with myocardial ischemia are asymptomatic (with pain or without pain the ischemia has the same prognosis)

28. Prinzmetal’s Angina • Occurs at rest usually d/t spasm of major coronary artery • Spasm may occur in the absence of CAD

29. Unstable Angina • Angina that is: • New in onset • Occurs at rest • Has a worsening pattern • Unpredictable • Considered to be an acute coronary syndrome • Associated with deterioration of a once stable atherosclerotic plaque

30. Clinical Manifestations Angina • Chest pain or discomfort (d/t ischemia) • A strange feeling, pressure, or ache in the chest • Constrictive, squeezing, heaving, choking, or suffocating sensation • Indigestion, burning

31. However… • Up to 80% of patients with myocardial ischemia are asymptomatic • Associated with diabetes mellitus and hypertension

32. Location of Chest Pain Fig. 33-12

33. Diagnostic StudiesAngina • ECG • Coronary angiography • Cardiac markers (CK MB, Troponin) • Treadmill exercise testing (stress test) • Serum lipid levels • C-reactive protein (CRP) • Nuclear imaging

34. Coronary Angiography • A diagnostic test using x-rays to record the passage of a contrast dye in the heart • To identify the presence, location and nature of any coronary artery disease • The heart valves and heart muscle can also be assessed

35. Coronary Angiogram

36. Coronary Angioplasty Video Link • http://www.healthscout.com/animation/1/38/main.html

37. Collaborative CareAngina • Treatment for stable angina: •  oxygen demand and/or  oxygen supply • Nitrate therapy • Stent placement

38. Collaborative CareAngina • Treatment for stable angina: • Percutaneous coronary intervention • Atherectomy • Laser angioplasty • Myocardial revascularization (CABG)

39. Coronary Artery Bypass Surgery • Is open heart surgery, which a bypass ( detour) is made to go around an area of blockage in a coronary artery • Bypasses are usually taken from the leg veins or an artery from the inside of the chest wall

40. Collaborative CareAngina • Drug Therapy • Antiplatelet aggregation therapy • Aspirin: drug of choice (for MI prevention) • First line of treatment for angina

41. Collaborative CareAngina • Drug Therapy • Nitrates • 1st line therapy for treatment of acute anginal symptoms • Dilation of vessels

42. Collaborative CareAngina • Drug Therapy • -Adrenergic blockers • Calcium channel blockers

43. Collaborative CareAngina • Percutaneous coronary intervention • Surgical intervention alternative • Performed with local anesthesia • Ambulatory 24 hours after the procedure

44. Collaborative CareAngina • Stent placement • Used to treat abrupt or threatened abrupt closure and restenosis following PCI

45. The Coronary Stent Procedure • A coronary stent is a small tubular wire object inserted into a coronary artery at the time of angioplasty to keep the previously narrowed artery open

46. Collaborative CareAngina • Atherectomy • The plaque is shaved off using a type of rotational blade • Decreases the incidence of abrupt closure as compared with PCI

47. Collaborative CareAngina • Laser angioplasty • Performed with a catheter containing fibers that carry laser energy • Used to precisely dissolve the blockage

48. Collaborative CareAngina • Myocardial revascularization (CABG) • Primary surgical treatment for CAD • Patient with CAD who has failed medical management or has advanced disease is considered a candidate

49. Clinical Manifestations Myocardial Infarction • Pain • Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration • The hallmark of an MI

50. Serum Cardiac Markers (Lewis p.817) • Creatine Kinase (creatine phosphokinase) (CK-MB) • Increased in > 90% of MI patients. • Begins to rise 4-6 hours • Peaks 24 hours • Returns to normal in 2 - 3 days • Troponin • Myocardial muscle protein released after an injury • Troponin T and Troponin I are cardiac specific indicators of an MI • Much more specific than CK-MB • Rises quickly and remains elevated for 2 weeks