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CORONARY ARTERY DISEASE OVERVIEW Pathogenesis, Clinical Features, Diagnostic Testing and Therapy. Hank George, FALU, CLU, FLMI.

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coronary artery disease overview pathogenesis clinical features diagnostic testing and therapy
CORONARY ARTERY DISEASE OVERVIEWPathogenesis, Clinical Features, Diagnostic Testing and Therapy

Hank George, FALU, CLU, FLMI

johannes a schaar erasmus medical college amsterdam circulation 108 2003 2636

“Myocardial infarction, sudden death and unstable angina have in common a genesis of coronary thrombosis, which develops as a result of a ruptured vulnerable or an eroded atherosclerotic plaque. As long as atherosclerotic lesions do not rupture and eroded plaques do not induce thrombosis, coronary disease may be a clinically silent disease associated with low mortality. Whenever plaques start to rupture and thrombogenic material is coming into contact with circulating blood, a situation is created which may lead to acute coronary syndrome associated with high mortality”

Johannes A. Schaar

Erasmus Medical College, Amsterdam

Circulation 108(2003):2636

what do we know about atherosclerosis
What do we know about atherosclerosis?
  • It is a diffuse, systemic disease of the arterial tree
  • It may be present and even severe despite the absence of recognized clinical symptoms
  • It may produce no extra mortality or morbidity…until it destabilizes resulting in VULNERABLE PLAQUE
what characterizes a vulnerable plaque

What characterizes aVULNERABLE PLAQUE?

Typically, a non-obstructive atheroma having a central lipid core, a thin fibrous cap and a yellowish appearance.

what can trigger an acute coronary event by inducing destabilization of a vulnerable lesion
What can trigger an acute coronary event by inducing destabilization of a vulnerable lesion?
  • Temperature change
  • Smoking a cigarette
  • Sexual activity
  • Vigorous exercise in a deconditioned person
  • Acute mental stress
  • Pollution
  • Infection
  • Excess hydration
  • Day-to-day dietary changes
  • Severe periodontal disease
what is the endothelium

What is the “endothelium?”

What is the role of the endothelium?

The lining covering the internal surface of blood vessels, heart valves and bodily cavities

It protects the artery from injury

by maintaining an antithrombotic

surface, mediating vasodilation

and inhibiting inflammation

what is endothelial dysfunction

What is endothelial DYSFUNCTION?

What induces DYSFUNCTION?

Disruption of normal function, leading to vasoconstriction, endothelial inflammation and thrombus formation

Inflammation, excess oxidized LDL-cholesterol

and many other complex biological factors

slide8

How do we know that inflammation occurring outside the coronary arteriesis associated with acute coronary syndromes?

Because patients with systemic inflammatory diseases such as rheumatoid arthritis and SLE develop endothelial dysfunction and have excess CAD

coronary artery disease four main presentations
Coronary Artery DiseaseFour Main Presentations

SILENT ISCHEMIA

CHRONIC STABLE ANGINA PECTORIS

ACUTE CORONARY SYNDROMES

UNSTABLE ANGINA PECTORIS

MYOCARDIAL INFARCTION

silent ischemia
SILENT ISCHEMIA
  • Ischemic changes on ECGs in the absence of clinically-recognized symptoms
  • Most common in diabetics due to neuropathy
  • As significant as chronic stable angina in terms of the subsequent risk of ACS events, as well as mortality and morbidity.
chronic stable angina
CHRONIC STABLE ANGINA
  • Episodes of chest pain and other symptoms (dyspnea, fatigue) induced by increased oxygen demand and relieved with cessation of inciting activity or Rx
  • Patients often have 2-3 times more silent episodes than symptomatic episodes
  • BEST CASEShave minimal excess mortality when compared to the general population
slide13
Presents with typical chest pain, induced by typical symptoms

May be presumptively diagnosed by symptoms only

Due to fixed obstructive disease

Managed as outpatient

Treated medically or surgically – often by patient choice

Presents like MI with prolonged chest pains, etc.

Diagnosed by ECG and cardiac markers

Due to intraluminal thrombus formation in vulnerable disease

Managed in hospital

Treated by percutaneous coronary intervention (PCI)

STABLE

UNSTABLE

chest pain episode underwriting triage
CHEST PAIN EPISODEUnderwriting Triage
  • Age,gender
  • CV profile
  • Where did patient present? ER? GP office?
  • Were Sx typical or atypical
  • What brought it on?
  • What brought relief?
  • Referral to non-cardiologist?
  • Management
troponin
TROPONIN
  • Myocardial proteins cTnT + cTnI
  • Essential component of MI diagnosis
  • Elevate from heart muscle damage;more sensitive and specific than CK-MB
  • Degree of elevation during/after MI key to long term prognosis
  • Elevates in other scenarios, including after noncardiac surgeries
  • These elevations are adverse mortality predictors even in absence of structural/functional heart damage
nt probnp finest cv marker ever
NT-proBNPFinest CV Marker EVER
  • Elevations due to myocardial stretch
  • Elevates in all forms of cardiac disease
  • Predictive of future mortality in subjects free of known CV disease
  • Independent of usual CV risk factors
  • Inexpensive
  • Recent report says protective value pay-off from this test is FANTASTIC
  • Will replace subjective (treadmill, ECG) CV screening in underwriting
other candidates for cv screening
Other candidates for CV screening
  • HbA1-c
  • Cystatin C
  • Apolipoprotein B:A1 ratio
diagnostic testing in cad
Diagnostic Testing in CAD
  • Resting ECG
  • Treadmill stress ECG
  • Stress echocardiogram –exercise vs. dobutamine(why can’t he exercise?)
  • Myocardial scintigraphy (thallium, etc.)
  • Noninvasive CT angiography
  • Invasive angiography(presurgical?)
disease assessment parameters
Disease Assessment Parameters
  • Exercise ischemia
  • Treadmill performance
  • Reversible vs. irreversible lesions
  • Left ventricular ejection fraction (LVEF)
  • Wall motion: hypokinesis, dyskinesis, akinesis
  • Degree of fixed obstructive disease
cac coronary artery calcium
CACCoronary Artery Calcium
  • Scanned for with helical and electron beam computed tomography
  • Extent of calcium quantified
  • Range 0-400
  • Very low risk with scores 0-10;just the opposite with 101-400
  • Readily available to consumers for $200 = antiselection potential!
medical management
MEDICAL MANAGEMENT
  • Antianginals: nitroglycerin, isosorbide dinitrate, mononitrates
  • Beta-blockers or calcium channel blockers as alternative antianginals
  • Clopidogrel, aspirin as antithrombotic prophylaxis
  • Statin prophylaxis
  • Lifestyle modification
surgical management
SURGICAL MANAGEMENT
  • Percutaneous coronary intervention, with or without stenting (PCI)
  • Coronary artery bypass grafting (CABG)
  • CABG has less long-term cardiac morbidity in terms of symptom recurrence
  • No difference in 10 year prospective mortality

Bravata. Annals of Internal Medicine. 147(2007):703

does surgical management lead to lower subsequent mortality than medical management

Does surgical management lead to lower subsequent mortality than medical management?

It depends on which study you believe!

Overall, this does not matter nearly as much as(1)the extent of heart damageand(2)how the patient responds to the diagnosis in terms of compliance and lifestyle choices

what factors should be considered in potentially insurable cad cases
What factors should be considered in potentially-insurable CAD cases?
  • Extent of myocardial damage
  • Current myocardial function, based on interim testing
  • Nature and extent of treatment
  • Compliance with Rx
  • Risk factor improvement (BP, lipids)
  • Health habit changes (quit smoking, exercise)…and
slide25

…one more:whether or not the individual is depressed, based on symptoms, need for treatment, etc.Many recent studies have shown that depressed CAD patients have significantly greater intermediate and longer-termmorbidity and mortality

chest pain with normal coronary anatomy
CHEST PAIN with normal coronary anatomy
  • Mostly women
  • Chest pain has features of angina
  • Often positive stress test
  • Further evaluation shows no evidence of significant obstructive coronary disease
  • Microvascular disease often present
  • No significant extra mortality
  • Substantial excess morbidity
stress cardiomyopathy
STRESS CARDIOMYOPATHY
  • Takotsubo cardiomyopathy,apical ballooning syndrome
  • 82% postmenopausal females
  • Induced by severe stress, also acute medical illness and after surgery
  • Presents like ACS
  • No obstructive lesions
  • Normalization of left ventricular function in 1-3 months in most cases
  • Supportive care only
  • Recurrence rate 2-10%

What is the long-term mortality risk?