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ATHEROSCLEROSIS
Lecturer – prof. Yu.R. Kovalev
GENERAL CONSIDERATIONS
TCh – Ch HDL
CA = --------------------- (r.u.)
Ch HDL
PERIPHERICAL SIGNS OF ATHEROSCLEROSIS
2 – Lipoid infiltration
3 – Fibrotic changes, mild calcinosis
4 –Severe calcinosis
5 – Ulcers of vessel wall
ATHEROSCLEROTIC PLAQUE STRUCTURE
Cholesterol
Smooth muscle cells crystals
DEVELOPMENT OF ATHEROSCLEROSIS
•Endothelial injury
•Proliferation of smooth muscle cells
•Synthesis of connective tissue matrix
•Focal accumulation of monocytes/macrophages (foam cells)
•Lymphocyte infiltration
•Intracellular and extracellular lipid accumulation
•Stenotic lesions
Atheroma commonly affects the proximal
portions of the epicardial vessels. This
may lead to single or multiple
obstructions. Most frequently affected
vessel is the anterior descending branch
of the left coronary artery. In left
circumflex branch and main left artery
plaques are also often located. Right
coronary artery is affected more rarely.
MORE FREQUENTLY AFFECTED
VESSELS
In atherosclerosis, focal fibrofatty
elevations (plaques) develop in the intimal
and subintimal regions resulting in
progressive narrowing of the lumen.
Severe complications may develop. These
include hemorrhage into the atheroma,
ulceration of subintimal surface,
embolisation of the atheromatous plaque,
thrombosis starting at the narrowed
portions of the arteries, and calcification.
LESION PROGRESSION IN A FIBROFATTY
PLAQUE
A – adventitia,
FC – fibrous cap,
C – calsification
F – obvious fissure
MP – myofibroblastic
proliferation
Progressive occlusion of the lumen of the
coronary arteries may remain totally
asymptomatic till the circulation is
considerably diminished. In general the
development of complications gives rise to
one of the clinically detectable syndromes.
STABLE ANGINA PECTORIS
The term "angina pectoris" is used to denote
the pain or discomfort produced by reversible
myocaidial ischemia brought on by exertion or
emotion and relieved by rest.
Ischemic cardiac pain starts and increases
with exertion or emotion and forces the patient to
stop activity. With rest the pain completely subsides
within a few minutes.
At times the manifestation may be only undue
dyspnoea or vague chest discomfort rather than the
clearcut pain.
STABLE ANGINA PECTORIS
Stenosis of coronary lumen consists 75% or more
stenosis stenosis
Conductor
Inflated balloon
Reperfusion
INTRACORONARY STENTS
The problem of PTCA is
restenosis.
Stenting may prevents
restenosis processes.
The restenosis is much
more rare if stents are
covered by cytostatics.
CORONARY ARTERY BYPASS GRAFTING
Chronic management
•Long acting nitrates
•Long acting calcium antagonists
•Selective α -adrenoblockers may be useful
•In patients with atherosclerotic stenosis -
revascularization
SILENT ISCHEMIA
This is not uncommon even in apparently
normal individuals. Routine stress testing
may bring out the abnormality. Such cases
may develop acute myocardial infarction or
die suddenly as a result of ventricular
fibrillation or cardiac arrest.
Significant abnormalities in the treadmill
test are indications for coronary
arteriography. Occlusion of the left main
coronary artery or all the three vessels is
an indication for early bypass surgery.
PREVENTION OF IHD