TERMS TO REMEMBER:

1. Coronary arteries: carry oxygen-rich blood to the heart’s muscular

walls (myocardium)
2. Myocardial infarction: blood flow to the heart muscle is blocked,
and tissue death occurs from loss of oxygen, severely damaging a
portion of the heart
3. Atherosclerosis: hardening and narrowing of arteries by fat deposits
called plaque that causes blockage of arteries (ischemia) and
prevents oxygen-rich blood from reaching the heart
4. Plaque: sticky substance made up of fat, cholesterol, calcium, and
other substances found in the blood
5. Coronary artery disease: end result of atherosclerosis
6. Metabolic syndrome: pre-diabetic condition that is significantly
associated with heart disease
7. Acute coronary syndrome: refers to rupture of an atheromatous
plaque in a diseased coronary artery, which rapidly forms an
obstructive thrombus
8. Echocardiogram: noninvasive test that uses ultrasound images of
the heart to see whether a part of heart muscle has been damaged
and not moving normally
9. Troponins: most specific biomarkers for diagnosing heart attack
10. Atherothrombosis: occurs when an atherosclerotic lesion disrupts;
obstructs coronary blood flow and causes ischemia in the myocardium
supplied by the artery

PREDISPOSING FACTORS PRECIPITATING FACTORS

 Age  Time
- Atherosclerosis: arteries age - The longer the blockage
by age remains in place, the more
- Menopausal age damage is caused to the heart
 Gender muscle
- Women have a better lipid - Because the heart can’t grow
profile than men new cells, the damage can’t be
- Women’s risk for heart disease undone
 increases after menopause
 Genetic Factors and Family
History
 Race and ethnicity (African
Americans)
- High rates of severe high
blood pressure, diabetes and
obesity
 Obesity and Metabolic
syndrome
- Low HDL cholesterol
- High triglyceride levels
 Unhealthy cholesterol levels
 Hypertension
- Contributes to the rate at
which atherosclerotic plaque
accumulates within arterial
walls
- Multifactorial condition
 Diabetes
- Risk for high blood pressure
and unhealthy cholesterol
levels, blood clotting problems,
kidney disease, and impaired
nerve function, all of which can
damage the heart
 Physical inactivity
- Exercise improve cholesterol
levels and blood pressure and
maintaining weight control
 Smoking
- Can cause elevated blood
pressure, worsen lipids, and
make platelets very sticky,
raising the risk of clots
 Alcohol
- Causes raised blood pressure
and heart rate, and irregular
heart beat; weakens the heart
 Financial stability
 Use of NSAIDs
- Elevate blood pressure and
cause heart failure
 Acute Psychological Stress
- Acute mental stress leads to
plaque destabilization and
thrombus formation
 People with multiple other
medical problems
1. Chronic Tophaceous Gout
- The inflammatory activity
associated with gout can itself
be proatherogenic and
promote a prothrombotic
environment that leads to
acute coronary events. Gout
can be expected to increase
the risk of acute myocardial
infarction (MI).
2. CKD
- CKD is associated with
accelerated atherogenesis,
due to the presence of both
traditional and non-traditional
(related to the underlying
uremic state) risk factors, and
any degree of renal
insufficiency portends a
worsened prognosis in
patients with CAD
- Significantly increased risk of
hospital mortality and major
bleeding episodes
3. CAP
- Acute respiratory infections are
associated with the damaging
combination of reduced myocardial
contractility, increased myocardial
 muscle; and raises levels of fat
in the blood (triglycerides)
 Diet
- Reducing intake of trans fats,
saturated fats, and cholesterol
and restricting salt intake that
contributes to high blood
pressure
 People with a history of
heart disease or multiple
risk factors for heart disease
oxygen demand and reduced
myocardial oxygen delivery.
- Infection also results in increased
myocardial oxygen demand
secondary to systemic vasodilation,
tachycardia and catecholamine
release. Catecholamines cause
coronary vasoconstriction and
endothelial dysfunction. In addition,
patients with respiratory infections
are frequently hypoxic.
Consequently, despite the increased
oxygen demands described in
sepsis, there may be significantly
reduced myocardial oxygen delivery.
Reduced myocardial oxygen
delivery may lead to myocyte
necrosis. Cardiac troponin levels are
a sensitive marker of myocyte
necrosis and are frequently elevated
in sepsis and are related to sepsis
severity, as well as left ventricular
dysfunction in sepsis.
4. Asthma
- Some studies reported on
phenomena occurring in
asthma such as inflammation,
infection, oxidative stress or
activation of blood platelets as
potential mechanisms leading
to the acceleration of
atherosclerosis. Not only
asthma itself, but also the
antiasthmatic drugs may have
an influence on the vessel
status.
 ELECTROCARDIOGRAM (ECG)

 P wave: contractions of the atria (the two chambers that receive

blood from outside the heart)
 QRS: series of waves associated with ventricular contractions (two
major pumping chambers in the heart)
 T and U: waves follow the ventricular contractions
 P-R interval: time it takes for an electrical impulse to travel from the
atria to the ventricles
 ST wave: interval between ventricular depolarization and
repolarization
 MEDICATIONS

1. Antiplatelets- prevent blood platelets from sticking together

ASPIRIN

CLOPIDOGREL

2. Anticoagulants- “blood thinners” that reduce the ability of blood to clot

HEPARIN

3. All anti clotting drugs increase the risk of bleeding

4. Beta blockers- reduce the oxygen demand of the heart by slowing the
heart rate and lowering pressure in the arteries
- Maintenance therapy- help prevent future heart attacks
- Non selective and selective
- Non selective can narrow bronchial airways (bawal dito patient natin,
kasi may asthma siya)
5. Statins- help lower cholesterol
6. Angiotensin converting enzyme inhibitors- widen or dilate blood
vessels
- For hypertension
7. Calcium channel blockers- for those who do not respond to nitrates
and beta blockers
8. Nitrates- cause vasodilation by relaxing smooth muscle in arteries
and veins; reducing venous return to the heart which decreases
cardiac preload; reducing workload on the myocardium and thus the
oxygen demand

PATHOPHYSIOLOGY
□ Coronary artery with atherosclerotic lesion (plaque)
- These lesions are prone to disruption due to underlying inflammation
in the lesion
□ Disruption of lesion
 - The lesion may disrupt as a result of a complete rupture or due to
erosion of the cap of the lesion
STE-ACS (STEMI) NSTE-ACS (NSTEMI)
Atherothrombosis causing total Atherothrombosis causing partial
obstruction of blood flow obstruction of blood flow
Type of ischemia: Transmural Type of ischemia: Subendocardial
- Ischemia/infarction stretches - Only the subendocardial layer
from the endocardium to the is affected
epicardium in the affected
region
ECG: ST elevations ECG: ST depressions

HISTORY

Current medications: Losartan- treating high blood pressure

Ventolin- treat asthma

Ketoanalogue- CKD

Febuxostat- gout

Philippine Heart Center:

1. Aspirin (antiplatelet)
- This acts by blocking the enzyme cyclooxygenase resulting in
decreased thromboxane A2 production and platelet inhibition
2. Clopidogrel (antiplatelet)
- Thienopyridine (P2Y12 receptor blockers):

DUAL ANTIPLATELET THERAPY (DPT)

>optimal antiplatelet effect

>bleeding risk

3. Tramadol
 - Pain activates the sympathetic nervous system which leads to (1)
peripheral vasoconstriction, (2) positive inotropic effect and (3)
positive chronotropic effect. This increases the workload on the heart
therefore aggravates the ischemia

COURSE IN THE WARD

This is a case of a 76 year old male admitted to our institution on August

26, 2018

 Low salt, low fat renal low purine diet

- Sodium acts like a sponge in your body, making it hold onto water.
Moving this extra water through your body requires your heart to work
harder, which raises blood pressure.
- Purines are a natural substance found in some foods. Purines aren’t
all bad, but you want to avoid high amounts. When your body digests
purine, it produces a waste product called uric acid. A buildup of uric
acid crystals in the joints can cause certain health issues. The main
ones are kidney stones and a type of arthritis known as gout.
 Meds upon admission
1. Clopidogrel (thienopyridines)- antiplatelet
2. Enoxaparin- anticoagulant
3. Atorvastatin- decrease LDL
4. Carvedilol- Beta blocker- reduce oxygen demand and ventricular wall
tension
5. Captopril- Ace Inhibitor- effective antihypertensive
6. Pantoprazole- counter side effects of thrombolytics
7. Furosemide- diuretic
8. Cefuroxime- Pneumonia
9. Azithromycin- Pneumonia
10. N-acetylcysteine- Mucolytic
11. Duavent- anti-asthmatic
12. Febuxostat- gout
13. Ketoanalogue- CKD
 Home meds
1. Tamsulosin + Finasteride- BPH Benign Prostatic Hyperplasia
2. Colchicine- gout
3. Amlodipine- antihypertensive
4. Clopidogrel- antiplatelet
5. Atorvastatin- decrease LDL
6. Febuxostat- Gout
7. Ketoanalogue-CKD
8. Isosorbide Mononitrate-antianginal
9. Isosorbide Dinitrate-antianginal
- Isosorbide dinitrate or mononitrate is used for the acute relief of
angina pectoris, for prophylactic management in situations likely to
provoke angina attacks, and for long-term prophylactic management
of angina pectoris.