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CORONARY ARTERY DISEASEPRESETATION AND INVESTIGATION

Dr. Zahoor Ali Shaikh

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CORONARY ARTERY DISEASE (CAD)

CAD is most common form of heart disease and causes premature death.

In UK, 1 in 3 men and 1 in 4 women die from coronary heart disease.

Approximately 1.3 million people have angina every year.

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CORONARY ARTERY DISEASE

Stable Angina It is due to transient myocardial

ischemia and occurs when there is increased demand of oxygen by heart.

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CORONARY ARTERY DISEASE

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STABLE ANGINA

RISK FACTOR FOR STABLE ANGINA Hypertension Diabetes Mellitus Aortic valve disease

- Angina is precipitated by - Anemia - Throtoxicosis

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INVESTIGATIONS

ECG Exercise ECG – Exercise tolerance

test (ETT). We monitor ECG, BP, and general

condition of patient.

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INVESTIGATIONS

Myocardial Perfusion Scan - Thallium stress test

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INVESTIGATIONS

Coronary Arteriography - Usually performed with a view to

percutaneus coronary intervention (PCI) or coronary artery bypass graft (CABG)

NOTE – PCI is done under local anesthesia in cardiac cath lab.

- CABG surgery is done using left internal mammary artery or Saphenous vein.

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INVESTIGATIONS

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MANAGEMENT OF ANGINA PECTORIS

Assessment of patient Look for risk factors Advise to the patient

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MANAGEMENT OF ANGINA PECTORIS

Antiplatelet therapy – aspirin Antianginal drugs -Nitrate -Beta blocker -Calcium antagonist

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ASPIRIN

Inhibits platelet aggregation Inhibits synthesis of prostaglandin

Thromboxone A2 and promotes reperfusion and reduces likelihood of thrombosis

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NITRORGLYCERINE (NTG)

Action It is venous and arteriolar dilator,

therefore, decreases venous return and preload

Decreases intraventricular volume and ventricular wall tension, therefore, decreases myocardial oxygen demand

Sublingual NTG – peak action 4-8 minute, action last for 10-30 minute

Side effect - headache

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BETA BLOCKER

Beta blocker are very good for angina associated with effort

Beta blocker decrease heart rate, blood pressure, and contractility of heart

Therefore, decrease oxygen demand

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CALCIUM CHANNEL BLOCKER

Action Cause coronary dilatation and

increase coronary flow Decrease myocardial contractility

therefore decrease oxygen demand

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CORONARY ARTERY SPASM

It is called variant angina or Vasospastic or prinzmetal angina.

Angina pain is due to spasm of coronary artery.

ECG may show transient ST-elevation Treatment is with calcium blocker,

nitrates.

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ACUTE CORONARY SYNDROME (ACS)

ACS is term used for 1. Unstable Angina 2. Myocardial infarction [MI] – NSTEMI 3. Myocardial infarction [MI] – STEMI Unstable Angina occurs at rest or minimal

exertion in absence of myocardial damage. MI symptoms occur at rest and there is evidence

of myocardial damage, demonstrated by increased level of cardiac Troponin or creatinine kinase-MB.

IMPORTANT – Troponin is more specific

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UNSTABLE ANGINA

There is partial/intermittent occlusion of coronary artery

Chest pain occurs at rest and lasts for more than 20 minutes

ECG – ST depression, T wave changes (T inversion)

Cardiac enzyme – Troponin T & I are normal Because No myocardial damage has occurred

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NSTEMI

Chest pain occurs at rest and lasts for more than 20 minutes

ECG – ST depression, T wave changes (T inversion)

Cardiac enzyme – Troponin T & I are increased Because myocardial damage has occurred

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STEMI

Severe Chest pain occurs at rest and lasts for 30 minutes to 1 hour

ECG – ST elevation, T wave changes later Q wave appear Cardiac enzyme –Troponin T & I are

increased and CK-MB increased

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STEMI (cont)

In STEMI, there is severe damage to the myocardium due to occlusion of blood flow in the coronary artery that causes death of myocardial tissue

Sudden death from ventricular fibrillation or asystole within 1 hour can occur.

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Patient with chest pain

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ACUTE CORONARY SYNDROME (ACS)

Diagnosis Evaluation of ECG Measurement of biochemical markers of

cardiac damage e.g. Troponin I and T, creatine kinase

Cardiac Troponin T and I are most sensitive and specific marker of myocardial cell damage

NOTE – Cardiac Biochemical markers are raised in MI. There is no rise in cardiac markers in angina.

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ACUTE CORONARY SYNDROME (ACS)

Other blood test - WBC count - ESR - C-reactive protein - X-ray chest - Echo cardiography

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MANAGEMENT

Admit the patient Morphine IV for pain Aspirin Nitrate Beta-blocker Calcium channel blocker Reperfusion therapy Percutaneous Coronary Intervention

(PCI)

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PCI

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COMPLICATIONS OF ACUTE CORONARY SYNDROME

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THANK YOU