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Coronary Artery Disease and Acute Coronary Syndrome

Coronary Artery Disease and Acute Coronary Syndrome. Description. Coronary Artery Disease (CAD) A type of blood vessel disorder that is included in the general category of atherosclerosis. Description. Atherosclerosis Can occur in any artery in the body Atheromas (fatty deposits)

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Coronary Artery Disease and Acute Coronary Syndrome

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  1. Coronary Artery Disease and Acute Coronary Syndrome

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

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

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

  5. 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

  6. 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

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

  8. 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

  9. 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

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

  11. Response to Endothelial Injury Fig. 33-3

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

  13. 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

  14. Collateral Circulation Fig. 33-5

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

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

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

  18. 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

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

  20. 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

  21. Silent Ischemia

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

  23. 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

  24. 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

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

  26. Location of Chest Pain Fig. 33-12

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

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

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

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

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

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

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

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

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

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

  37. 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

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

  39. Clinical Manifestations • Acute Coronary Syndrome (ACS) • Develops when the oxygen supply is prolonged and not immediately reversible

  40. Clinical Manifestations • ACS encompasses: • Unstable angina • Myocardial infarction (MI)

  41. Relationships Among CAD, Stable Angina, and MI Fig. 33-8

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