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Atherosclerosis Invasiv and noninvasiv investigations

Atherosclerosis Invasiv and noninvasiv investigations. Dr. Mátyás Keltai. The Framingham Study: Relationship Between Cholesterol and CHD Risk. 150. 125. 100. 75. CHD incidence per 1000. 50. 25. 0. <204 (<5.3). 205-234 (5.3-6.1). 235-264 (6.1-6.8). 265-294 (6.8-7.6). >295 (>7.6).

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Atherosclerosis Invasiv and noninvasiv investigations

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  1. AtherosclerosisInvasiv and noninvasiv investigations Dr. Mátyás Keltai Cardiology 2009

  2. The Framingham Study: Relationship Between Cholesterol and CHD Risk 150 125 100 75 CHD incidence per 1000 50 25 0 <204 (<5.3) 205-234 (5.3-6.1) 235-264 (6.1-6.8) 265-294 (6.8-7.6) >295 (>7.6) Serum total cholesterol, mg/dL (mmol/L) Cardiology 2009 Castelli WP. Am J Med. 1984;76:4-12

  3. Cholesterol: A Modifiable Risk Factor • In the USA, 51% (105 million) have elevated total cholesterol (>200 mg/dL, 5.2 mmol/L)1 • In EUROASPIRE II, 58% of patients with established CHD had elevated total cholesterol (5 mmol/L, 190 mg/dL)2 • 10% reduction in total cholesterol results in: • 15% reduction in CHD mortality (p<0.001) • 11% reduction in total mortality (p<0.001)3 • LDL-C is the primary target to prevent CHD Cardiology 2009 1. American Heart Association. Heart and Stroke Statistical Update; 2002; 2. EUROASPIRE II Study Group. Eur Heart J 2001;22:554-572; 3. Gould AL et al. Circulation 1998;97:946–952.

  4. subclinical symptomatic healthy Old paradigm about the progression of atherosclerosis Threshold Weeks-Days Years Decades Intima Lumen Media Plaque • Stable angina • Stable angine with narrowing • Easy diagnostics (ECG, angiography) • MI rear • Treatment simple Cardiology 2009 Antischkow N. Beitr Path Anat Allg Path 1913;56:379-404.

  5. subclinical symptomatic Healthy New paradigm Threshold Months-Days Decades Years-months Thrombus Intima Lumen Media Plaque • Unstable angina (Acute coronary syndrome) • Unstable angina with narrowing • Difficult diagnosis (MR, IVUS, OCT) • Frequent MI • Prevention is simple Cardiology 2009

  6. Migration of leucocytes into the artery wall Lipoprotein infiltration Increased endothelial permeability Leucocyte adhesion Endothel dysfunction Upregulation of endothelial adhesion molecules Cardiology 2009

  7. Adherence and aggregation of platelets Migration of smooth muscle cells Formation of foam cells Activation of T cells Adherence and entry of leucocytes Fatty Streak Formation in Atherosclerosis Cardiology 2009

  8. Formation of necrotic core Accumulation of macrophages Formation of the fibrous cap Formation of the Complicated Atherosclerotic Plaque Cardiology 2009

  9. Thinning of the fibrous cap Rupture of the fibrous cap Haemorrhage from plaque microvessels The Unstable Atherosclerotic Plaque Cardiology 2009

  10. Intraluminal thrombus Lipid pool Intraplaque thrombus Atherosclerotic Plaque Rupture and Thrombus Formation Cardiology 2009

  11. Clinical evaluation of heart diseases • History • Physical • Clinical chemistry • EKG • Echocardiography • Nuclearcardiology • Invasive investigations Cardiology 2009

  12. IHD is a benign disorder • Fatty streak appears already in teenagers • Coronary lesion os less than 50 % diameter, or 70 % area stenosis don’t cause symptoms • Long intervals with or without medical treatment are symptomfree. • Problems arise only, when the intracoronary plaque becomes unstable Cardiology 2009

  13. Patients’ history (Hx) • Based on thorough Hx, focused on physical exercise-related symptoms, and also physical exam reveal sufficient information for the physician to estimate the probability of IHD. • Use diagnostic algorhythms to construct your work-up Cardiology 2009

  14. The definition of stable angina • Angina is a clinical syndrome characterized by dyscomfort in the chest, jaw, or shoulder, irradiating into the back os the arm (left). • It is typically aggravated by exertion or emotional stress • It is usually relieved by sublingual NG • All the three criteria must be present Cardiology 2009

  15. Angina usually means coronary artery disease (CAD) • Angina usually developes in pts with CAD in >1epicardial coronary artery • Angina may develope in patients without significant CAD (hypertension, HOCM, valvar heart disease) especially in those who prone to coronary spasm (because of endothelial dysfunction). • Differentiate form esophaegeal, and chest wall-disorders-caused symptoms Cardiology 2009

  16. Wording of typical anginal pain • Usual words : Squeezing, griplike, pressure, suffocating - angina, heaviness • Sometimes not pain - only discomfort • Almost never sharp, stabbing, stiching • Typical gesture - closed fist on the chest • No changes with posture or inspiration, lasts few minutes, ceases with rest or NG Cardiology 2009

  17. The CCS Classification of AP • I. Only strenouos, prolonged exercise results in angina, but normal daily activities don’t • II. Normal daily activity is slightly limited (morning, cold, 2 blocks, or flights) • III. Marked limitation of normal daily acitivity • IV. Inability to carry on any physical activity without discomfort. Angina may be present at rest. Cardiology 2009

  18. New York Heart Associationclassification of HF • I. Usual daily activity does not cause symptoms • II. More strenous, than usual activity (> 2 blocks, or flights) causes dyspnea • III. Moderate physical activity (<2 blocks, or flights) causes dyspnea • IV. Dyspnea at rest Cardiology 2009

  19. Physical investigation • General impression • Edema, cyanosis, dystended neck veins • Blood pressure. Body weight, height, BMI • Heart enlargement, apical impulse • Murmurs, thrills (Heart, carotids, femorals) • Pulmonary percussion, rales, • Hepatic enlargement • Peripheral pulses Cardiology 2009

  20. Loudness of murmurs • Very faint • Faint • Audible • Loud • Very loud – with thrills • Maybe heard with distant stethoscop Cardiology 2009

  21. EKG methods • 12 lead EKG • Rhythm strip • Holter monitoring (PM memory) • Event monitoring • Signal averaged EKG • Intracardial EKG (electrophysiology) • Transtelephonic EKG • Vectorcardiography Cardiology 2009

  22. Clinical chemistry 1. • Riskfactors • Diabetes (IGT,IFG) • Fasting, 120 postprandial, HgbA1C • Hyperlipoproteinaemia • Total cholesterol, HDL, LDL, TG • Inflammatory markers (Wgr.,CRP, adhesion molecules, antibodies) • Necrosis markers (CK-MB, troponin) • BNP in heart failure Cardiology 2009

  23. Clinical chemistry 2. • Hypertension: • Renal function: urines analysis, BUN, Se kreatinin, Clearance, albuminuria • Endocrinology: renin, TSH, T4, • Treatment otpimalisation: • Electrolyte measurements: Se Na, K, Haematology, Se digoxin, serum level of antbiotics • Side effect disclosure: ASAT, ALAT, CPK, GGT, haematology, TSH, T4, renal function Cardiology 2009

  24. Imaging modalities • Chest x-ray • Chest CT • Echocardiography • Transthoracale (TTE) • Transesophageale (TEE) • MR • Multislice CTA, Cardiology 2009

  25. Chest x-ray • Anteroposterior and lateral exposures • Contours, heart enlargement, heart volume measureable • Pulmonary vascularisation ( pulmonary hypertension, pulmonary venous pressure) • Comparable Cardiology 2009

  26. Chest x-ray and CT Cardiology 2009

  27. Echocardiography • Non-invasive diameters, wall thickness, valve movements • Non-invasive hemodynamic evaluation by Doppler ultrasound flow measurements • Pressure gradients • Pathologic flow (qualitative, quantitative) Cardiology 2009

  28. EchocardiographyM-mode registration Cardiology 2009

  29. Echocardiography 2-D registration Cardiology 2009

  30. Echocardiography in CAD • Class I. indication: • patients with systolic murmur (AS, HOCM) • Evaluation of the severity of ischemia (segmental wall motion abnormality) during pain, or within 30 minutes after pain • Class II. indication: • Patients with a click, or murmur suggestive MVP Cardiology 2009

  31. Nuclear cardiology • Many possibilities • Cardiac index - J125 red blood cells • Perfusion (Technetium, Thallium) • Viability • Long imaging time • Linear, or single photon SPECT • EBCT - CTA • MRI Cardiology 2009

  32. Exercise ECG • Exercise ECG is a well established procedure used for decades. • Safe (MI or death 1/2500) • 20-30 % of patients are unable to perform ETT because of contraindication • Bicycle and treadmill are both useful. • Use standard, comparable protocols Cardiology 2009

  33. ETT standards • Supervised by a physician (personally?) • 1 MET = 3,5 ml/kg/min oxygen uptake • Continuous monitoring for heart rate, blood pressure, ST segment shift, arrhythmias • Target 85 % of maximal HR, or angina, or >2 mm ST depression (horizontal, or downsloping) • Maximal HR= 220 - age Cardiology 2009

  34. Costs of ETT • ECG ETT is cheap • Stress echocardiography twofold • SPECT scintigraphy fivefold • Coronarography twentyfold Cardiology 2009

  35. Interpretation of ETT • Lead selection - more leads-more information • Upsloping ST segment depression • ST segment elevation - rare, great likelihoood of arrhythmias, probable transmural ischemia • R wave changes are not reliable Cardiology 2009

  36. Class I indication for ETT • Patients with an intermediate probability of CAD (based on age, gender, symptoms) including patients with RBBB or < 1 mm ST depression at rest • Excluding patients with WpW sy., PM rhythm. More than 1 mm ST depression at rest, LBBB. • Established CAD -functional capacity, prognosis Cardiology 2009

  37. Exercise imaging tests • Myocardial scintigraphy (specificity: 70-85 %, sensitivity: 85-90 %) • MIBI, or Thallium • SPECT, or planar • Physical exercise, or pharmacological stress • Stress echocardiography: (specificity: 60-90 %, sensitivity: 85-94 %) • low-dose dobutamine infusion stress Cardiology 2009

  38. Indications for stress imaging as initial test • Class I.: • Intermediate probability of CAD and WPW, or <1 mm ST depression • In patients with previous revascularisation • Intermediate probability of CAD and PM rhythm, or LBBB - use adenosine or dipyridamole stress scintigraphy or dobutamine -echo in patients who are unable to exercise Cardiology 2009

  39. Invasive investigations • Essentials are pressure measurement, flow measurement, angiocardiography, coronarography • Coronarography • Pressure measurement • Direct or indirect (fluid coloumn) • Pressure difference • Gradients (peak or mean) Cardiology 2009

  40. Technique of coronary arteriography • Percutaneous insertion of catheter • femoral - preformed catheter (Judkins) • brachial - Sones • Fluoroscopy • Contrast dye injection • Pressure measurement • Digital or x-ray cinefilm recording Cardiology 2009

  41. Risks of coronary arteriography • Vascular, Arrhythmias, Allergic reactions, Bleeding, Thrombosis, Stroke, AMI • Morbidity <1 % • Mortality < 1 %o Cardiology 2009

  42. Value of coronary arteriography • Most accurate diagnostic tool for obstructive atherosclerotic and non-atherosclerotic (Kawasaki, spasm, dissection) coronary disease. • The only means to disclose coronary anatomy Cardiology 2009

  43. Medical therapy of angina • A: Aspirin (antiplatelet) and Antianginal (nitrate), ACEI • B: Beta receptor blocker and Blood pressure control • C: Cigarette smoking and Cholesterol lowering • D: Diet and Diabetes control • E: Education and Exercise Cardiology 2009

  44. ACC/AHA Classification • Class I.:Conditions for which there is evidence or general agreement to be useful - SHOULD • Class IIa.: Conflicting evidence, diverging oppinions, but in favour of efficacy – MAY BE • Class IIb.: Conflicting evidence, diverging opinions, less well established efficacy – CAN BE • Class III.: There is evidence, or general agreement to be ineffective, not useful, can be even harmful –DO NOT Cardiology 2009

  45. Ranking of evidences in ACC/AHA guidelines • A level evidence: Multiple randomized, clinical trials, with large number of patients • B level evidence : Small randomized trials, or careful analysis of nonrandmized trials, or registries • C level evidence: No randomized trials, based on expert consensus Cardiology 2009

  46. Class I Indication for AP-Aspirin • Aspirin inhibits cyclooxygenase and platelet thromboxane A2 • 30-35 % reduction of cardiovascular events (AMI, stroke CV death) • Frequent GI side-effects • Does not block all pathways of platelet aggregation • If contraindicated - clopidogrel Cardiology 2009

  47. Class I indication for AP - Beta blockers • Beta blockers decrease HR, afterload (BP), and contractility, the major determinants of oxygen demand • Aim: resting HR: 55-60/min • BB are indicated for the initial therapy of AP both for post MI and non MI patients • Survival benefit proven only post MI • Contraindications….. Cardiology 2009

  48. Class I indication for AP - Ca channel blockers • Ca channel blockers reduce the transmembrane flux of Ca through the Ca chanells • Negative inotrop, reduce smooth muscle cell tension - vasodilation - also in the coronaries • Reduce blood pressure • Indicated if BB are ineffective, cause serious side effects, or in combination Cardiology 2009

  49. Class I indication for AP - long acting nitrates • Nitrates are endothelium independent coronary vasodilators, reduce oxygen requirement, venodilators, decrease blood pressure • Indicated if BB are ineffective, cause side effects, or in combination • Side effects (headache) • Problem: nitrate tolerance Cardiology 2009

  50. Class I. indication for AP - short acting nitrates • Sublingual nitroglycerin, or nitroglycerin spray for the immediate relief of angina • In case of long lasting pain (suspected AMI) repeat three doses in 5 minute intervals Cardiology 2009

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