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CORONARY ARTERY DISEASE OVERVIEW Pathogenesis, Clinical Features, Diagnostic Testing and Therapy. Hank George, FALU, CLU, FLMI.
Hank George, FALU, CLU, FLMI
“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
Typically, a non-obstructive atheroma having a central lipid core, a thin fibrous cap and a yellowish appearance.
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 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
Because patients with systemic inflammatory diseases such as rheumatoid arthritis and SLE develop endothelial dysfunction and have excess CAD
CHRONIC STABLE ANGINA PECTORIS
ACUTE CORONARY SYNDROMES
UNSTABLE ANGINA PECTORIS
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)
Bravata. Annals of Internal Medicine. 147(2007):703
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
…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
What is the long-term mortality risk?