Stable Coronary Artery Disease - Yeditepe University Cardiology Course

1. Stable coronary artery disease YEDITEPE UNIVERSITY FACULTY OF MEDICINE PHASE 4 CARDIOLOGY COURSE 2014-2015 PROF. MUZAFFER DEGERTEKIN, M.D., PhD. MUSTAFA AYTEK SIMSEK, M.D., Attending Physician

2. Atherosclerotic Cardiovascular Diasease • Stable Ischemic Heart Disease • Acute Coronary Syndrome • ST-Segment Elevation Myocardial Infarction • Unstable Angina and Non–ST Elevation Myocardial Infarction

3. Definition Coronary artery disease: • used to describe coronary arteries affected by a pathological process. • the narrowing of the coronary arteriesor blockage of coronary blood flow, usually caused by atherosclerosis. • This can cause chest pain, shortness of breath, or myocardial infarction.

4. Nonatherosclerotic CAD • Coronary artery spasm • Arteritis/vasculitis • Occlusion of a coronary artery due to dissecting aneurysm • Coronary embolism • Syphilitic aortitis involving the coronary ostia • Cocaine induced vasospasm • Vasospasm and/or thrombosis due to hypersensitivity (Kounis syndrome) • Congenital abnormalities

5. Definition Ischemic heart disease(Coronary heart disease or atherosclerotic heart disease) • Cardiac disease resulting from myocardial ischemia. • Although myocardial ischemia also occurs in such conditions as aortic stenosis or anemia, the term ‘ischemic heart disease’ is generally applied only to cases of atherosclerotic origin.

6. Definition • Arteriosclerosis –a general term describing any thickening and hardening of artery walls and loss of elasticity of medium or large arteries. • Atherosclerosis– process where fatty material is deposited along walls of arteries. This material thickens, hardens, and can eventually block the artery. • Atherosclerosis is just one type of arteriosclerosis

7. 2013 SCAD GUIDELINE

9. Magnitude of the Problem • The leading cause of death • The lifetime risk of developing symptomatic CAD after age 40 (Framingham Heart Study) • 49% for men • 32% for women

11. Angina Angina is a type of chest discomfort caused by poor blood flow through the coronary vessels to myocardium(≥70% reduction in luminal diameter of a major coronary artery).

12. Angina: Exertional Coronary artery obstructions are not sufficient to result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results. Angina:VariantAngina • Transient impairment of coronary blood supply by vasospasm or platelet aggregation • Majority of patients have an atherosclerotic plaque • Generalized arterial hypersensitivity • Long term prognosis very good

13. Angina: Silent Ischemia • Very common • More episodes of silent than painful ischemia in the same patient • No pain, but ischemic ECG changes • Most common in diabetics (due to neuropathy) Difficult to diagnose • Holter monitor • Exercise testing • As significant as chronic SAP in terms of the subsequent risk of ACS events, as well as mortality and morbidity.

14. Symptoms other than angina: • Breathlessness • Feeling of faintness • Anxiety • Flatulence or other dispeptic complaints

15. Angina: Anginal Equivalent Syndrome • Patient’s with exertional dyspnea rather than exertional chest pain • Caused by exercise induced left ventricular dysfunction • Shortness of breath, diaphoresis

16. Evaluateangina pectoris • Location • Characteristics • Precipitating factors • Duration • Relieved

17. Location • Usually substernal, • May extend to • the left or right chest, • the shoulders, • the neck, • jaw, • arms (usually ulnar surface of left arm), • epigastrium and the upper back) • Occasionally,the radiated pain may be more noticeable to the patient than the origin of the pain

18. Characteristics • Deep, visceral and intense • Many patients describe it as a • pressure–like, • squeezing sensation • Rather than • sharp or • stabbing or • pinprick-like pain

19. Precipitating factors • Exercise, • heavy meal, • cold weather • the emotional stress • Other events that obviously increase myocardial oxygen demand, such as • rapid tacharrhytmias, • extreme elevations in blood pressure, • decrease in oxygen supply such as anemia.

20. Duration • Angina pectoris is transient lasting between 2 and 30 minutes. • Typically 2-10 minutes • The duration of the pain is minutes, not seconds, not hours • Chest pain that lasts longer than 30 min is more consistent with myocardial infarction, pain of less than 2 min is unlikely to be due to myocardial ischemia

21. Relieved by • cessation of the precipitating event such as exercise, or • the administration of treatment such as sublingual nitroglycerine.

22. Angina – Types: • Typical Angina: • Atypical Angina: • Noncardiac chest pain • Stable Angina:reproducible, predictable • Unstable Angina:new onset, increased freq, intensity, duration, or occurs at rest

24. Pre Test Probability of Coronary Disease by Symptoms, Gender and Age

25. CCSC Angina Classification

27. Physical Examination • May be completely normal • S3 or S4 may be heard • Mitral regurgitation • Blood pressure • Body mass index • Waist circumference

29. Electrocardiogram (ECG) • All patients with suspected angina should have a resting ECG. • May be completely normal (especially between attacks of angina) • Evidence of old myocardial infarction, bundle branch block, left ventricular hypertrophy

30. Electrocardiogram (ECG) • Ischemia at rest: “non-specific T and ST changes” • changes in the T-wave or the ST segment that are “out of place” • normally, the T-wave and the QRS complex have similar polarity • T-wave flattening: • T-wave inversion: • ST-segment scooping: • ST-segment depression:

31. AVR AVL AVF Inferior Ischemia in a 42 year old male at rest I II III

32. Anteriolateral ischemia in a 67 year old female while at rest V1 V4 V2 V5 V3 V6

34. Laboratory Examination • Hemoglobin • Creatinine • Glucose • Lipids • Thyroid function • High sensitive CRP • Homocysteine • NTproBNP • Troponins

36. Chest X-Ray • Patients with suspected heart failure • Patients with clinical evidence of significant pulmonary disease

38. Echocardiography Used to assess... • Myocardial Structures • MR, TR, AR • Ventricular Function • EF • Wall motion abnormalities • Effusions • Thrombus • Ischemia

40. measures Electro- cardiogram Stress Test shows measures Coronary Angiography specific blood electrical coronaries to heart Sites of supply impulses Narrowing in Screening and Diagnosis

42. Exercise Stress Testing • The most widely used • The least expensive CAD screening modality

43. Exercise stress test • Ischemia during exercise: ST-segment depression • usually indicative of subendocardial ischemia • location of ischemia does not always correspond to the leads in which it is seen Baseline Quantity or depth of ST-segment depression J-point .08 seconds

44. Treadmille • Continued until • The patient becomes fatigued • Achieves 85% of the maximum predicted heart rate (approximately 220 minus the patient's age) • Terminated • Signs or symptoms of severe ischemia (angina, ST-segment elevation, ST-segment depression >0.3 mV, or a fall in blood pressure of 10 mm Hg), arrhythmias, or heart block develop

45. Treadmille

46. ST Segment Interpretation • Computer summaries can help find possible areas of ischemia – then review raw data carefully! • Determine PQ junction, J point, ST80, and estimate slope • Elevation • Depression • Upsloping • Horizontal • Downsloping

47. Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with a relatively stable baseline are selected. The PQ junction (1) and J point (2) are determined; the ST 80 (3) is determined at 80 msec after the J point. In this example, average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The average slope measurement from the J point to ST 80 is –1.1 mV/sec.

48. Normal Rapid Upsloping Minor ST Depression Slow Upsloping

49. Horizontal Downsloping Elevation (non Q lead) Elevation (Q wave lead)

50. Duke treadmill score = duration of exercise in minutes on the Bruce protocol - (minus) 5x maximal mm ST deviation - (minus) 4x treadmill angina index Treadmill Angina Index: 0 if no angina. 1 if non-limiting angina. 2 if limiting angina. High Risk = treadmill score < -1079% 4-year survival Moderate Risk = treadmill score -10 to +495% 4-year survival Low Risk = treadmill score >+599% 4-year survival