1. Coronary heart disease
Impaired cardiac function
due to inadequate
coronary circulation

2. Commonest cause- CAD
End result of accumulation of
atheromatous plaques in
coronary arteries

3. Non-atherosclerotic causes
 Coronary vasospasm- Prinzmetal angina
 Cardiac syndrome X- common in women
 Severe LV hypertrophy
 Severe aortic stenosis or regurgitation
 Congenital coronary artery anomaly
 Coronary artery emboli/dissection
 Increased cardiac demand- tachycardia,
anemia, hyperthyroidism

4. Risk factors for
atherosclerosis
 Non-modifiable- age, sex, family history
 Modifiable-
 Smoking
 Hypercholesterolemia- LDL, lipoprotein a
 Hypertension- systolic > diastolic
 Hyperglycemia- diabetes mellitus
 Type A behaviour- stress
 High fibrinogen, factor VII
 Hyperhomocysteinemia
 Obesity, sedentary lifestyle
 CRI

5. Pathophysiology
 Atherosclerosis is nearly universal & starts before
adulthood, leading to plaque formation
 Plaques cause narrowing of coronary arteries
 Stable plaque causes predictable angina
 Unstable plaque ruptures, activating clotting system &
thrombus formation, that impairs coronary blood flow
causing unstable angina or MI
 MI heals with scarring, causing impairing contractility
& increasing stiffness, leading to HF- acute/chronic
 Ischemic areas & scars are prone to cause
ventricular arrythmias, leading to sudden death

6. Manifestations
 Asymptomatic
 Angina-
 Acute- unstable- unpredictable
 Chronic- stable- predictable
 Myocardial infarction-
 Non ST elevated- NSTEMI
 ST elevated- STEMI
 Acute LVF
 Ischemic cardiomyopathy- CHF
 Sudden cardiac death

7. Clinical presentation
 Angina pectoris-
 Precordial/retrosternal/epigastric pain
 Described as tightness, squeezing, choking, indigestion
 Duration- <20 mins
 Radiation to left arm, shoulder, jaw
 Precipitated by exertion, stress, meal, cold, sex
 Relieved by rest or sublingual nitroglycerin
 Associated SOB, sweating, nausea, dizziness/syncope
 Unstable angina-
 Angina at rest, new-onset, more severe, increased frequency
 Myocardial infarction-
 Duration- >20 mins, not relieved by NTG

8. Evaluation
 Examination- HR, BP,
±S3/S4, murmur of MR
 Ix-
 Disease- ECG-ST elevation/depression, CxR,
Stress test-
TMT/radionuclide/ECHO,
ECHO- regional wall-motion abnormality,
Coronary angiography- CT or conventional, ±IVUS
 Risk factors- FBS, lipid profile, creatinine
 Precipitating factors- Hb, TSH

9. TMT- Treadmill test
 Bruce protocol-
 Increases treadmill speed & elevation every 3 minutes
 Indication-
 To confirm diagnosis of angina & determine severity
 To assess prognosis in patients with known CAD
 Screen those at high risk of CAD
 Interpretation-
 >1 mm flat or downsloping ST depression
 Severe disease- >2 mm depression, <6 mins. of exercise,
HR <70% predicted for age & hyper/hypotension

10. Coronary angiography
 For definitive diagnosis of CAD
 Indication- if PTCA/CABG an option-
 Limiting stable angina on adequate medical Rx
 High-risk disease- ACS or high-risk TMT
 Concomitant aortic valve disease
 Older patients undergoing valve surgery
 Recurrence of angina after PTCA/CABG
 Cardiac failure with surgically correctable lesion
 Survivors of SCD or VT
 Chest-pain or cardiomyopathy of unknown etiology

11. Treatment
 Medical-
 Aspirin- anti-thrombotic-1° & 2° prevention
 β-blockers- decrease cardiac workload- 2° prevention
 Statins- plaque stabilization & reduction- 2° prevention
 ACEI- cardiac remodelling- MI/HF
 Percutaneous- PTCA ± stent placement
 Bypass- CABG
 Experimental-
 Angiogenic growth factors- FGF-1, VEGF
 Stem-cell therapy
 Risk factor modification

12. Risk factor modification
 Quit smoking
 Control HT
 Control DM
 Control LDL
 Reduce stress
 Reduce weight
 Active lifestyle

13. Complication
 Recurrent ischemia- more after NSTEMI than STEMI
 Arrythmia- bradycardia, AV block, VT
 Shock- urgent PCI, ± IABP support
 Acute MR/VSD- supportsurgical correction
 Myocardial rupture- kills
 Heart failure- diuretics, nitrates, dobutamine
 Aneurysm- surgery, if required
 Mural thrombus ± embolization-
UFH/LMWHwarfarin

14. Chronic stable angina
 Angina occuring predictably on exertion &
relieved by rest or sublingual NTG
 Normal troponin & CK-MB
 ECG-
 Resting ECG- normal
 During anginal episode-
>1 mm ST depression ± T wave
flattening/inversion (ST
elevation seen in Prinzmetal angina)
 ECHO- for RWMA & LVEF
 Exercise testing- TMT
 Coronary angiography, if indicated

15. Treatment
 Sublingual NTG- for acute pain
 Prevention of attacks-
 Treat/avoid aggravating factors
 Aspirin (alternative- clopidogrel)
 Statins
 β-blockers
 ± long-acting nitrates
 ± CCB
 Risk factor modification

16. Revascularization
 Indication-
 Symptomatic despite adequate medical Rx
 Left main coronary artery stenosis
 Triple vessel disease with LVEF <50%
 Unstable angina
 Post-MI angina or +ve TMT
 Modalities-
 PCI- with stent- bare metal/drug eluting- placement
 CABG- preferred for L main/TVD with low
LVEF/T2DM

17. Acute coronary syndrome- ACS
 Unstable angina & myocardial infarction
 Unstable angina- cardiac markers- normal
 Angina at rest, new-onset, more severe, increased frequency
 With ST depression on ECG & normal Trop-T/I or CK-MB
 Myocardial infarction- cardiac markers- high
 Angina- lasts longer & not responsive to S/L NTG
 Rise of cardiac biomarkers- Trop-T/I & CK-MB
 With ECG changes- new Q waves/LBBB,
non-ST elevated-NSTEMI or ST elevated-
STEMI
 ECHO- new loss of viable myocardium or new RWMA

18. Recoverable myocardium
Hibernating- chronic ischemia
Stunned- post-MI
Evaluation- ECHO

19. Treatment of NSTE ACS
 Admit- rest, monitoring, ?oxygen
 Aspirin- 325 mg
 Clopidogrel- 300 mg stat75 mg OD
 Anticoagulation- UFH/LMWH
 Nitrates- for symptomatic relief
 β-blockers- as tolerated
 CCB- as add-on to nitrates & β-blockers
 Statins
 GP IIb/IIIa inhibitors- for intended early cath/PCI or
for high-risk patients- eptifibatide, tirofiban, abciximab

20. Indication for early angiography
All patients with ACS, except
those with normal stress test-
TMT/ECHO/radionuclide

21. STEMI
 Common in early morning
 ~1/2 have preceding angina- ignored
 1/3rd
without chest-pain,
specially diabetics
 e/o HF- poor prognosis
 Trop T/I- early MI, CK-MB- reinfarction

22. Treatment
 Admit- rest, morphine, ?oxygen, monitoring
 Aspirin + Clopidogrel
 β- blockers- early, if no contraindications
 ACEI- early, if no hypotension
 Statins
 Reperfusion-
within 12 hours of onset, sooner the better
 Options- for reperfusion
 1° angioplasty- with stenting & GP IIb/IIIa inhibitors
 Thrombolytic therapy- streptokinase, alteplase, tenecteplase-
followed by anticoagulation x 7 days

23. Post-infarction- no angiography
No complications
Preserved LVEF >50%
No exercise induced ischemia

24. Major differences
 Unstable angina-
 Trop T/I & CK-MB- normal
 Rx- Asp + Clopidogrel + UFH/LMWH ± GP IIb/IIIa inhibitors
 Early coronary angiography- Dx & Rx
 NSTEMI-
 Trop T/I & CK-MB- raised
 Rx- as for unstable angina
 Early coronary angiography
 STEMI-
 Trop T/I & CK-MB- raised
 Rx- Asp ± Clopidogrel + 1° PCI/Thrombolysis
 No angiography- post-MI normal LVEF & normal stress test