Coronary artery diseases

2. CAD is an imbalance between the supply of
oxygen and the myocardial demand resulting in
myocardial ischemia usually due to coronary
artery disease (atherosclerosis of the coronary
arteries).

3. EPIDEMIOLOGY
 CAD is the leading cause of death worldwide
of men and women over 20 years of
age, responsible for about 1 in every 5
deaths (40% of all deaths >35 years of age).
 Prevalence of CAD among those older than
20 years in developed countries is 6.4%
(7.9% in men and 5.1% in women)
 Prevalence of CAD in India is approximately
11% in the urban population and 7% in the
rural population.
 In African countries (including Nigeria)
prevalence of CAD is approximately 2.6 %.
 CAD is the most common cause of sudden
death.

4. RISK FACTORS
CAD is associated with factors such as:
o hypertension,
o diabetes mellitus,
o dyslipidaemia (is increasing in urban areas),
o tobacco smoking,
o obesity (commoner in women than men),
o sedentary life style
The alternative risk factors include homocysteine, C-
reactive protein (CRP), lipoprotein (a), coronary calcium
and more sophisticated lipid analysis.

9. EXTRA-LUMINAL PLAQUE
High risk of
progression without
previous history of
angina

10. Characteristics of
unstable and stable plaque
Thin
fibrous cap
Inflammatory
cells
Few
SMCs
Eroded
endothelium
Activated
macrophages
Thick
fibrous cap
Lack of
inflammatory
cells
Foam cells
Intact
endothelium
More
SMCs
Circulation. 1995;91:2844-2850.
Unstable Stable

12. Classification of CAD
 Sudden death
 Myocardial infarction
 Unstable angina
 Stable angina (chronic CAD,Chronic coronary
syndrome)
 Asymptomatic CAD (silent ischemia)

13. (Chronic CAD
CCS)

14. Diagnostic plan
1. Observation and physical examination
2. Laboratory investigations (used to identify possible
causes of ischaemia, to establish cardiovascular risk factors
and associated conditions and to determine prognosis).
3. ECG at rest
4. Exercise stress test
5. EchoCG and other ultrasound technologies
6. Coronary angiography
7. Nuclear stress test

15. Signs and Symptoms
 Chest pain: If coronary arteries can’t
supply enough blood to meet the
oxygen demands of heart, the result
may be chest pain called angina.
 Shortness of breath: Some people may
not be aware they have CAD until they
develop symptoms of congestive heart
failure - extreme fatigue with exertion,
shortness of breath and swelling in their
feet and ankles.
 Heart attack: Results when an artery to
heart muscle becomes completely
blocked and the party of heart muscles
fed by that artery dies.
 None: This is referred to as silent
ischemia. Blood to heart may be
restricted due to CAD, but patient
doesn’t feel any effects.
Signs &
Symptoms
None
Chest
Pain
Shortness
Of Breath
Heart
Attack

16. 1. Characterized by
• substernal discomfort,
• heaviness,
• or a pressure-like feeling
2. May radiate to the jaw, shoulder, back, or arm
3. Typically lasts 5-15 minutes.
4. These symptoms are usually brought on by
exertion, emotional stress, cold, or a heavy
meal
5. Relieved by rest or nitroglycerin within
minutes.
ANGINA PAIN

17. * In most cities in the USA & Canada a "block" is 1/16 of a
mile (100 meters).

18. Is often normal, unless the patient is seen during an
episode of pain, when tachycardia or transient arrhythmia
may be present.
Features which may indicate predisposing factors include:
 Signs of hyperlipidaemia
 Evidence of vascular disease
 Elevated BP.
 Conditions other than coronary heart disease which can
occur with angina including aortic stenosis, uncontrolled
atrial fibrillation, cardiomyopathy
Physical examination

19. Laboratory investigations
• Full blood count including hemoglobin and white
cell count is recommended in all patients.
• A fasting lipid profile (including LDL) is
recommended for all patients.
• HbA1c and fasting plasma glucose
• Creatinine measurement and estimation of renal
function (creatinine clearance) are recommended
in all patients
• If indicated by clinical suspicion of thyroid
disorder assessment of thyroid function is
recommended
• Liver function tests are recommended in patients
early after beginning statin therapy

20. A resting ECG is recommended in all patients
ECG
A normal resting ECG is not uncommon, even in patients
with severe angina, and does not exclude the diagnosis of
ischaemia.
Ambulatory ECG monitoring should be considered in
patients with suspected arrhythmias and vasospastic angina.

21. Stress testing
Stress testing offers the most diagnostic
information in those patients at “intermediate
risk” of having coronary artery disease.
Goals:
•Diagnosis of CAD
•Prognosis implications
•Risk assessment after MI
•Evaluation of suitability for transplant
•Hemodynamic evaluation in valvular disease
Bicycle Treadmill test

22. EchoCG
1. Rest EchoCG
-Size of chambers
-Valvular disease
-Ejection fraction
2. Stress EchoCG
-Areas of hypokynesis
-Viability of myocardium
3. IVUS
-real-time high-resolution images allowing
precise tomographic assessment of lumen
area, plaque size, and composition of a
coronary segment

24. Coronaroangioagraphy
The Gold Standard ????

26. PROBLEMS
•Cost
•Invasive
•Complications: 1:1000 risk of
•Death
•MI
•Stroke
•Vascular complications
•Others
•Does not provide information on
functional significance of CAD

27. MRI and CT
MRI is an imaging technique that takes advantage of the property of certain atomic nuclei (in this case, the
single proton that forms the nucleus of a hydrogen atom) to vibrate – or “resonate” – when exposed to
bursts of magnetic energy. When the hydrogen nuclei resonate in response to changes in a magnetic field,
they emit radiofrequency energy. The MRI machine detects this emitted energy, and converts it to an
image.

28. TREATMENT

29. Goal of therapy
A return to normal activities and
functional capacity
For most patients the goal of
treatment is to be completely free of
angina or CCS class I angina or
better
Address other modifiable risk factors
such as cholesterol, smoking, HTN,
DM, and exercise, weight

30. Stable Angina
Treatment Options
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32. Current Pharmacotherapy
 Nitrates (Nitroglycerin spray
acts more rapidly)
 Beta-blockers or calcium
channel blockers (verapamil)
 Aspirin
 ACE inhibitors
 Statins

33. Percutaneous coronary
intervention
 PCI is indicated for patients with single-or double-
vessel disease with significant proximal LAD CAD,
who have normal LV function and who do not have
treated diabetes
 Compared with conservative therapy, PCI does not
decrease mortality or the risk of MI during follow-
up in patients with chronic CAD.

34. Revascularization - CABG
CABG has survival benefit
when there is
Left main stenosis
3,2, or 1 vessel disease
that includes proximal
LAD
3 vessel disease
(without prox. LAD),
with poor LV function