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MEDICINE II
1.1K CORONARY ARTERY DISEASE: ACUTE & CHRONIC CORONARY SYNDROMES

OBJECTIVES
To discuss the pathophysiology, different clinical presentations and physical
findings in coronary artery disease.
To discuss the basic methods in diagnosing CAD
To enumerate the management strategy in treating patients with CAD.

PATHOPHYSIOLOGY OF MYOCARDIAL ISCHEMIA

Coronary artery disease (CAD) generally refers to atherosclerosis of the coronary

arteries that may results in significant obstruction to coronary blood supply leading
to myocardial ischemia
Myocardial ischemia refers to a condition in which there is an imbalance between
the oxygen supply and oxygen demand of the myocardium usually due to a severe
fixed or dynamic obstruction of the myocardial blood supply, or an increase in
myocardial oxygen requirements, or both.

SPECTRUM OF CORONARY ARTERY DISEASE

PATHOGENESIS OF ATHEROSCLEROTIC PLAQUE

Endothelial Dysfunction and Inflammation
CLINICAL MANIFESTATIONS OF CHRONIC CORONARY ARTERY DISEASE

Symptoms

Physical examination

Biochemical tests

ECG

Other ancillary tests

The Fatty Streak

The Advanced Plaque

The Ruptured Plaque

ANGINA PECTORIS
Angina pectoris is a discomfort of the chest or adjacent areas caused
by myocardial ischemia
Usually brought on by exertion or stress
Constricting, crushing, heavy, squeezing in character
Retrosternal in location but may radiate to other areas of the chest, ulnar
surface of the arms, more commonly the left arm, epigastrium, and
mandible
Begins gradually and reaches its maximum over a few minutes before
dissipating
May be associated with dyspnea, faintness and easy fatigability

Symptoms Not Suggestive of Angina Pectoris

Pleuritic pain; brought on by respiratory movement or cough

Pain located in the middle or lower abdomen

Pain localized with one finger

Pain reproduced by movement or palpation of the chest wall

Constant pain lasting for days

Very brief episodes of pain lasting a few seconds

Pain radiating to the lower extremities

Grading of Angina Pectoris
Canadian Cardiovascular Society Classification
Ordinary physical activity does not cause angina; angina occurs with
strenuous, rapid, or prolonged exertion.
Slight limitation of ordinary physical activity; angina occurs after walking >
2 blocks on the level or climbing > 1 flight of ordinary stairs at a normal
pace and under normal conditions.
Marked limitation of ordinary physical activity; angina occurs on walking 1
to 2 blocks on the level and climbing 1 flight of stairs at a normal pace
and under normal conditions.
Inability to carry on any physical activity without discomfort; angina may
be present at rest.

I
II

III
IV

DIFFERENTIAL DIAGNOSIS OF CHEST PAIN

Angina pectoris
Myocardial infarction

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1.1K CORONARY ARTERY DISEASE: ACUTE & CHRONIC CORONARY SYNDROMES

Aortic dissection
Pulmonary embolism
Acute pericarditis
Acute pleuritis
Severe pulmonary hypertension
Gastroesophageal reflux
Esophageal motility disorders
Biliary colic
Cervical radiculitis
Costochondritis

CORONARY FLOW RESERVE (STRESS)

R1 = driving pressure of large epicardial arteries
R2 = coronary arteriolar resistance
R3 = wall tension in the subendocardium

PHYSICAL EXAM IN CHRONIC CAD

Many patients with CAD have normal physical findings
General: corneal arcus, xanthomas, xanthelasma, retinal arteriolar
changes, elevated BP, diagonal earlobe crease, diminished arterial
pulses and bruits
Cardiac examination: During an episode of angina pectoris, one may
detect a S3, paradoxical splitting of S2, transient systolic murmurs, and
pulmonary rales. A displaced left ventricular impulse suggests
ventricular dysfunction
BIOCHEMICAL TESTS IN CHRONIC CAD
Lipid profile

total cholesterol

low density lipoprotein (LDL)

high density lipoprotein (HDL)

triglycerides
Fasting blood glucose
Other biochemical markers:

Lipoprotein Lp(a)

Homocysteine level

High sensitivity C- reactive protein

ELECTROCARDIOGRAM (ECG) IN CHRONIC CAD
Resting ECG is normal in 50% of patients with chronic stable angina
pectoris
Most common ECG findings in chronic CAD are non-specific ST-T wave
changes with or without Q waves
Various arrhythmias, especially ventricular premature beats may be
seen

EXERCISE ECG
Most widely used test to diagnose CAD
Usually performed on a treadmill or bicycle
Gives information not only on the presence or absence of ECG evidence
of ischemia but also on exercise capacity, blood pressure and heart rate
responses to exercise
ECG findings of horizontal or downsloping ST segment depression is
indicative of myocardial ischemia
Accuracy of ECG diagnosis may be limited in patients with abnormal
baseline ECG
Treadmill exercise test
Bicycle ergometry
ABNORMAL STRESS ECG

NON-INVASIVE STRESS TESTING

Provides useful information to establish the diagnosis and estimate the
prognosis in patients with chronic stable angina.
Most helpful in patients considered to have a moderate probability of
CAD based on clinical symptoms and normal ECG

CORONARY FLOW RESERVE (REST)

R1 = driving pressure of large epicardial arteries
R2 = coronary arteriolar resistance
R3 = wall tension in the subendocardium

OTHER FORMS OF NON INVASIVE STRESS TESTING

Nuclear Cardiology Techniques

Stress myocardial perfusion imaging

99
99

Uses either thallium, Tc sestamibi, or Tc

tetrofosmin

Pharmacologic nuclear stress testing

For patients unable to exercise adequately

May use Dipyridamole, Adenosine, or

Dobutamine to stress the heart

Positron emission tomography

Useful to detect myocardial viability

Stress Echocardiography

Exercise echocardiography

Pharmacologic stress echocardiography

Nuclear Gamma Camera
Radionuclide Myocardial Perfusion Imaging
Stress Echocardiography

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NEWER NON-INVASIVE IMAGING TECHNOLOGIES FOR CAD DIAGNOSIS

Computed tomography (CT)

Electron beam CT coronary calcium scoring

Multi-slice CT coronary angiography

Computed Tomography (CT) Coronary Angiogram

Magnetic resonance imaging

Cardiac Magnetic Resonance Imaging (MRI)

INVASIVE TESTING IN CAD

Cardiac catheterization and coronary angiography

Definitive diagnosis of CAD

Precise assessment of anatomical severity of CAD

Assessment of left ventricular function

Requires the insertion of a catheter in a peripheral artery

which is advanced intravascularly to the heart under
fluoroscopic guidance
Intravascular ultrasonography (IVUS)
Coronary Angiogram
Intravascular Ultrasound

The Vulnerable Coronary Atherosclerotic Plaque

Pathologic Findings in Acute Coronary Syndrome

ACUTE CORONARY SYNDROMES

Acute coronary syndrome

Refers to any constellation of clinical symptoms that are compatible with

acute myocardial ischemia

a spectrum of conditions that includes:

Unstable angina (UA)
Non ST elevation myocardial infarction (NSTEMI); also
referred to as non Q wave MI
ST elevation myocardial infarction (STEMI); also referred to
as Q wave MI

linked by a common pathogenesis, clinical presentation, and therapeutic

approach
Coronary Angiographic Findings in Unstable Angina / Non ST Elevation MI
SPECTRUM OF CORONARY ARTERY DISEASE

PATHOGENESIS OF ACUTE CORONARY SYNDROME

Evolution of the Atherosclerotic Plaque
Pathologic Findings in Non ST-Elevation Myocardial Infarction

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Coronary Angiographic Findings of A Patient With Anterolateral ST-Elevation

Myocardial Infarction

ECG FINDINGS O ST DEPRESSION AND T WAVE INVERSION

Pathologic Findings in Acute Myocardial Infarction (ST-elevation or Q-wave

MI)
MARKERS OF CARDIAC INJURY
Cardiac markers are macromolecular components of cardiac myocytes, consisting
mainly of enzymes or contractile proteins, that are released into the circulation
during myocardial necrosis or injury.
Currently Available Cardiac Markers

Aspartate Aminotransferase (AST)

Lactate Dehydrogenase (LDH)

LD1 isoenzyme

Creatine Kinase (CK)

CK-MB isoenzyme

CK isoforms

Myoglobin

Troponins

Troponin T (cTnT)

Troponin I (cTnI)
CLINICAL FEATURES OF ACUTE CORONARY SYNDROME
WHO Criteria for the Diagnosis of MI

a clinical history of ischemic-type chest discomfort

changes on serially obtained ECG tracings

rise and fall of serum cardiac markers

Principal Presentations of Acute Coronary Syndrome

Rest angina - usually >20 minutes

New-onset angina - at least CCS Class III

Increasing angina - previous angina that has become distinctly more

frequent, longer in duration, or lower in threshold (increased by > 1 CCS
Class to at least CCS Class III)
Acute Coronary Syndrome: ECG Findings

ST elevation with T wave changes with subsequent development of Q

wave

New bundle branch block

ST depression or T wave inversion

Nonspecific ST- T changes

Normal ECG

ACUTE CORONARY SYNDROMES

ECG FINDINGS OF ST ELEVATION

MANAGEMENT OF CORONARY ARTERY DISEASE

Lifestyle modification
Control coronary risk factors
Management of extracardiac contributing factors
Pharmacologic therapy
Coronary revascularization

NON PHARMACOLOGIC MEASURES IN THE MANAGEMENT OF CORONARY

ARTERY DISEASE

Lifestyle modification

Maintain ideal body mass index

2

BMI = weight (kg)/height (m)

Regular, aerobic physical exercise

Minimum of 30-45 mins 4x week

Healthy heart diet

Low salt, low fat, high fiber

Smoking cessation

CONTROL CORONARY RISK FACTORS

Hypertension

Goal is to maintain BP 130/80

In pts with CAD, beta-blockers, calcium antagonists, or ACE

inhibitors preferred
Diabetes mellitus

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1.1K CORONARY ARTERY DISEASE: ACUTE & CHRONIC CORONARY SYNDROMES

Maintain normal fasting and post prandial glucose, and

glycosylated hemoglobin; ACE or ARB inhibitors preferred
Dyslipidemia

Goals are more stringent in pts with CAD :

Total cholesterol = < 200%

LDL = < 70 mg%

HDL = > 45 mg%

Triglycerides < 150 mg%

Statins are drug of choice

EXTRA CARDIAC FACTORS WHICH MAY PROVOKE ANGINA

Fever
Hypertension
Anemia
Hypoxia
Tachyarrhythmias
Thyrotoxicosis
Illicit drug use

TREATMENT OF ACUTE CORONARY SYNDROME

ACUTE CORONARY SYNDROME : GENERAL MEASURES
Hospital admission
Oxygen therapy
Activity restriction
Diet
Bowel and bladder care
Sedatives and anxiolytics

PHARMACOLOGIC THERAPY OF ACUTE CORONARY SYNDROME

Analgesics

Anti-thrombotic drugs

Unfractionated heparin

Low molecular weight heparin

Glycoprotein IIB/IIIA platelet receptor inhibitor

Thrombolytic agents*

Streptokinase

t-PA

Antiplatelet agents

Aspirin

Clopidogrel (Plavix)

Ticlopidine (Ticlid)

Ticagrelor

Prasugrel

Anti-ischemic drugs

Nitrates sublingual, oral, topical

Beta-blockers

Calcium channel blockers

Angiotensin converting enzyme inhibitors

EFFECT OF ANTI-ISCHEMIC DRUGS

PHARMACOLOGIC THERAPY OF CORONARY ARTERY DISEASE: ANTIISCHEMIC AGENTS

PHARMACOLOGIC THERAPY OF ISCHEMIC HEART DISEASE: ACE

INHIBITORS

PHARMACOLOGIC THERAPY OF ISCHEMIC HEART IDEASE: ANTI PLATELET

AGENTS

PHARMACOLOGIC THERAPY FOR AMI: ANALGESICS

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PHARMACOLOGIC THERAPY OF UNSTABLE ANGINA OR NON Q-WAVE MI:

HEPARINS

Triage of Patients with Acute ST Elevation MI

Inhibition of Platelet Aggregation By Glycoprotein IIb/IIIa Receptor

Antagonists

PHARMACOLOGIC THERAPY OF UA OR NSTEMI: PLATELET GLYCOPROTEIN

IIb/IIIa INHIBITORS

Contraindications to Thrombolytic Therapy

Absolute Contraindications

Active internal bleeding (except menses)

Suspected aortic dissection

Recent head trauma or known intracranial neoplasm

History of hemorrhagic CVA

Major surgery or trauma < 2 weeks

Relative contraindications

Blood pressure >180/110

Active peptic ulcer disease

History of CVA

Known bleeding diathesis or current anticoagulant use

Prolonged traumatic CPR

Diabetic hemorrhagic retinopathy

Pregnancy

Prior exposure to STK or APSAC

ANTI-PLATELET & ANTI-THROMBOTIC THERAPY IN ACUTE CORONARY

SYNDROME

NON PHARMACOLOGIC THERAPY OF ISCHEMIC HEART DISEASE

Percutaneous Transluminal Coronary Angioplasty (PTCA) with or

without coronary stent implantation

Coronary Artery Bypass Grafting (CABG)

TREATMENT OF ACUTE CORONARY SYNDROME Q-WAVE (ST-ELEVATION)
MI
Management of ST Elevation Acute MI

- Coronary Stents

- PTCA With Stenting of the RCA

- Coronary Artery Bypass Grafting (CABG)

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