Coronary Artery Disease (CAD) : Pathogenesis RF

Coronary Artery Disease (CAD)
 Common cause of angina & acute coronary syndrome (ACS)
Pathogenesis RF
 Atherosclerosis : progressive inflammatory disorder of Non modifiable
arterial wall – focal lipid rich deposit of atheroma – b/c  Sex: M>F (pre-menopause), M=F (menopause)
larger – impair tissue perfusion, ulceration, disruption of  Age
lesion - cause thrombotic occlusion/ distal embolization of  Family h/o IHD
vessel Modifiable
 When predominant inflammation plaque – thinning  Hypercholesterolemia : high serum cholesterol, LDL
protective fibrous cap – vulnerable to mechanical stress –  DM II
erosion, fissuring, rupture of plaque – expose to blood –  Physical inactive
trigger platelet aggregation – thrombosis formation until  Obesity
atheromatous plaque & arterial lumen – partial/ complete  Excess alcohol consumption, smoking
obstruction – infarction/ ischemia
Stable angina/ Angina pectoris C/F

 Imbalance between myocardial oxygen supply & demand –  Central chest pain, discomfort – last 2-5 min, may radiate
myocardial ischemia to arms, back, jaw, epigastrium
Decrease O2 supply Increase demand  Dyspnea by exertion, emotion
 Mechanical obstruction:  Increase CO –  Relieved by stress
atheroma, thrombosis, Thyrotoxicosis  Sign for left ventricular dysfunction: cardiomegaly, gallop
spasm, embolus,  Myocardial hypertrophy rhythm
coronary arteritis - hypertension  Sign of AAA, carotid bruits, diminished arterial pulse in
 Decrease oxygenated lower extremities
b/flow: anemia,
hypotension, carnoxy- Ix:
hemoglobinemia  ECG: ST depression, cardiac rhythm, intraventricular
conduction
Treatment  Lipid profile: serum cholesterol, LDL, HDL, TG
 Nitrate : nitroglycerin  Urinalysis: glycosuria, microalbumineia (renal)
- Systemic venodilation, reduction in left ventricular  Blood test: Hct, HbA1c, creatinine
end-diastolic volume & pressure – reduce myocardial  Chest X ray: cardiac enlargement, ventricular aneurysm, HF
wall tension & O2 requirement  Exercise ECG: ST segment depression >=1mm  ischemia
 B adrenergic blocker  ECHO: assess left ventricular function w chronic stable
- Decrease HR, myocardial contractility – reduce angina, h/o MI, pathologic Q wave, clinical evidence of
myocardial O2 heart failure
- C/I: asthma, chronic lung disease
 CCB
- Coronary vasodilator – reduce myocardial
contractility, decrease O2 demand
 Aspirin
- Antiplatelet – interference platelet activation
Acute Coronary Syndrome (ACS)
 Composed of:
- Unstable angina: new onset (no rest pain), angina at rest within past months (<48 hrs – angina at rest, subacute), angina at
rest within 48 hrs (acute)
- NSTEMI – partial occlusion
- STEMI – complete occlusion
Criteria of diagnosis AMI Pathogenesis

 Detection of rise/ fall of cardiac biomarker values  Ulcerated/ fissured atheromatous plaque w adherent
 Symptoms of ischemia platelet rich thrombus & local coronary artery spasm
 Significant ST segment, T waves changes, LBBB  Presence of occlusive thrombus at rupture/ erosion of
 Development of pathological Q waves atheromatous plaque – artery occluded – ischemia -
 Imaging evidence of loss of viable myocardium/ regional irreversible myocardial damage – infarction
wall motion abnormality
 Identification of intracoronary thrombus by angiography/
post-mortem
C/F Investigations
 Central chest pain : tightness, heaviness  12 lead ECG
 Anxiety, fear of impending death - ST elevation: occlusion – full thickness infarction
 Breathlessness, vomiting, collapse - Diminution of R wave
 Sympathetic: Pallor, sweating, tachycardia - Inversion of T wave
 Vagal: vomiting, bradycardia - ST depression, T wave changes - Partial occlusion of
 Impaired myocardial function: hypotension, oliguria, cold major vessel/ complete occlusion of minor vessel 
periphery, narrow pulse pressure, raise JVP, 3rd heart unstable angina, subendocardial MI
sound, diffuse apical impulse, lung crepitation  Cardiac biomarker
- Serum troponin
Complications - Unstable angina: no detectable rise in troponin,
 Arrhythmia diagnosis based on clinical history & ECG
 Heart failure – extensive myocardial damage - MI: rise plasma troponin T & I (within 3-6 hrs, remain
 Pericarditis to 2 weeks)
 Recurrent MI
Management
 Analgesia : morphine
- Relieve distress, lower adrenergic drive – reduce
vascular resistance, BP, infarct size
 Establish early perfusion
- If symptoms of ischemia <12 hrs, persistent ST
segment elevation
 Treatment of complications
 FBC: leucocytosis (1st day), high ESR, CRP
 Lipid profile
 Chest X ray: cardiomegaly, pulmonary edema
 ECHO: assess ventricular function, detect mural thrombus,
cardiac rupture, VSD, mitral regurgitation, pericardial
effusion
 Coronary angiography: to revascularization in moderate/
high risk patient
Risk of stroke (CHADS2)
 CHF -1
 HTN -1
 Age >75 – 1
 DM – 1
 Stroke, TA -2

Coronary Artery Disease (CAD) : Pathogenesis RF

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Coronary Artery Disease (CAD) : Pathogenesis RF

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Coronary Artery Disease (CAD)

 Common cause of angina & acute coronary syndrome (ACS)

Stable angina/ Angina pectoris C/F

Criteria of diagnosis AMI Pathogenesis

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