1、Coronary Artery Atherosclerotic Heart Disease(Angina and Myocardial infarction)Epidemiology of Atherosclerosis DiseasesLeading cause of morbidity and mortality in world wideThe death rate of atherosclerosis is increase rapidly in the Third World Fortunately, The progression of atherosclerosis may be

2、 slowed even reversed with appropriate lifestyle and drug interventions Risk Factors:AgingThe adoption of a diet high in fat, calories and cholesterolphysical inactivity (as a potato on sofa) blood lipid abnormalities low-density lipoprotein cholesterolcigarette smokingSuffer from hypertension and d

3、iabetes mellitusGenic factors (heredity)genetic factoralcohol intaking pathogenesisLipid hypothesis (cholesterol into artery wall)Platelet aggregate and thrombus formation hypothesis (trigged by endothelial injure) Smooth cell clone hypothesis Inflammation hypothesis damaged from endothelial dysfunc

4、tion第期 初始病變(initial lesion)第期 脂質條紋期(fatty streak)第期 粥樣斑塊前期(pre-atheroma)第期 粥樣斑塊期(atheroma)第期 纖維斑塊期(fibroatheroma)第期 復雜病變期(complicated lesions ) Atherosclerosis in coronary artery Definition Coronary artery disease (CAD) results from progressive blockage of the coronary vessels by arteriosclerosis. C

5、linical syndromes result from an imbalance of oxygen supply and demand inadequate myocardial perfusion to meet metabolic demand (myocardial ischemia). Plaque hemorrhage or rupture with thrombosis are responsible for most ischemia syndromes.Anatomy（圖片）Types of CADlatent coronary heart disease with co

6、ronary artery atherosclerosis, but without symptomangina pectoris the most common in clinical practicemyocardial infarction with myocardial necrosis result from acute ischemiaischemic cardiomyopathy heart enlarge, failure and arrhythmia result from chronic ischemia sudden death in general, cardiac a

7、rrest result from a heart attack (may trigger the sudden onset of ventricular fibrillation)Chronic coronary artery disease Stable latent coronary heart diseaseischemic cardiomyopathyAcute coronary syndrome (ACS)Unstable angina, UANon-ST segment elevation myocardial infarction, NSTEMIST segment eleva

8、tion STEMI Angina Pectoris What Is Angina?Angina is chest pain or discomfort that occurs when myocardium does not get enough blood flowing. Angina is a symptom of coronary artery disease, the most common type of heart disease. CAD occurs when plaque builds up in the coronary arteries. The types of a

9、ngina The two types of angina are stable and unstable. It is very important to know the differences between the types. stable angina pectoris (demand ischemia) Stable angina is the most common type. It occurs when the heart is working harder than usual, and the episode in quality, location, duration

10、 of pain, provoke and relieve,etc. is stable.unstable angina (supply ischemia) Unstable angina is a very dangerous condition that requires emergency treatment. It may a sign that a heart attack could occur soon. pathogenesisSome plaque is hard and stable and leads to narrowed and hardened arteries.

11、By narrowing the artery to the point where the flow of blood is greatly reduced, which induce a stable angina.Other plaque is soft and is more likely to break open and cause blood clots. By forming blood clots that partially or totally block the artery (may be with spasm), which induce the unstable

12、anginal episodes.stable angina pectorisProvoke factors of anginaPhysical exertion is the most common cause of pain and discomfort from stable angina. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low . But with exertion, like walking up a hill , t

13、he heart works harder and needs more oxygen. Emotional stress Exposure to very hot or cold temperature Heavy meals Quality Pain and discomfort are the main symptoms of angina. These symptoms are often described as pressure, squeezing, burning, griplike, heavy or tightness May feel like indigestion ;

14、Some people say that angina discomfort is hard to describe or that they cant tell exactly where the pain is coming from. Location Usually start in the chest behind the breastbone or left lateral chest wall May also radiation to the left arms, shoulders, neck, jaw, throat, or back Symptoms vary based

15、 on the type of angina. 圖片 The pain or discomfort Duration and RelieveIs expected, and episodes of pain tend to be alike Usually lasts a short time (15 minutes or less) Is relieved by rest or angina medicine (Sublingual nitroglycerlin)And how frequency of angina ClassINo limitation of physical activ

16、ityIISlight limitation of physical activity. Ordinary activity results in fatigue, palpitation, dyspnoea, or anginal pain.IIIMarked limitation of physical activity. Less than ordinary activity causes fatigue, palpitation, dyspnoea, or anginal pain.IVInability to carry out any physical activity witho

17、ut discomfort. Symptoms may be present even at rest. Unstable Angina pathogenesis Unstable angina is caused by blood clots that partially or totally block an artery. If plaque in an artery ruptures or breaks open, blood clots may form. This creates a larger blockage. The clot may grow large enough t

18、o completely block the artery and cause a heart attack. Blood clots may form, partly dissolve, and later form again. Common condition of Unstable AnginaRest angina pectorisNew-onset angina pectorisAccelerated angina pectorisThe pain or discomfort: Often occurs at rest, while sleeping at night, or wi

19、th little physical exertion Is unexpected Is more severe and lasts longer (as long as 30 minutes) than episodes of stable angina Is usually not relieved with rest or angina medicine May get continuously worse May signal that a heart attack will happen soon The Signs when angina episodessweatinessA g

20、allop rhythm is found, occasionallyAn apical systolic murmur may be presentArrhythmias may be presentEvaluation of CAD Evaluation of patients with angina ECG(electrocardiogram) Resting ECG: the characteristic charge is horizontal or downsloping ST segment depression and T wave flattening or inversio

21、n. Stress Test: Some heart problems are easier to diagnose when patient heart is working harder and beating faster. During stress testing, patients exercise to make his heart work harder and beat faster while heart tests are performed. Ambulatory monitoring: May reveal evidence of ischemia that is n

22、ot provoked by exercise（1）EchocardiogramX-ray scan (computed tomography imaging)Coronary angiographyCoronary angiography The test is usually performed along with cardiac catheterization. A contrast that can be seen using x-ray is injected through the catheter into the coronary arteries. blockages ca

23、n be found from the flow of blood through the heart . （1）（1）（1）（1） differential diagnosisAcute myocardial infarction Angina by other causesThorax pain and other un-typical painpulmonary embolismcardiopericarditiscardiac neurosisPrevention and treatment of CADTreatment when angina episoderesting，oxyg

24、en supply.Nitrate medicine: such as nitroglycerin prevention and treatmentAspirin and Anticoagulation-block and Blood pressure controlCigarette off and Cholesterol level control (statins)Diet and DiabetesEducation and ExerciseChronic stable angina treatmentMedicine:Nitrates: such as Isosorbide dinit

25、rate(po.tid,520mg once) Pentaerythritol tetranitrate(po.tid,1030mg once) Beta blockers : Metoprolol( po.bid,12.550mg once) Propranolol (po.tid or qid,10mg once)calcium-channel blocker: verapamil(80mg,po.tid) nifedipine(1020mg,tid.po)Antiplatelet ： Aspirin enteric coated tablets(100mg,po.qd) clopidog

26、rel （75mg，po，qd）Lipid-lowering drug : Pravastatin sodium tablets(20-40mg,po.qd) Simvastatin tablets(1040mg,po.qn) Atrovastatin tablets(10-40mg,po.qn)Cononary artery bypass grafting(CABG)Percutaneous coronary artery Intervention (PCI)Percutaneous coronary artery Intervention (PCI) INDICATIONS ：main s

27、tenosis of local pathological changes 50% inadaptation for by-pass operation CONTRAINDICATION：stenosis 50%widespread and diffusible affection Percutaneous coronary artery Intervention (PCI)Percutaneous coronary artery Intervention (PCI)Percutaneous coronary artery Intervention (PCI)Percutaneous coro

28、nary artery Intervention (PCI)支架內再狹窄 糖尿病患者 小血管病變 長病變25%-30% 的患者StentBasecoat Basecoat = 聚合物 + 雷帕霉素 + Topcoat = 彌散屏障控制釋放雷帕霉素的聚合物Topcoat (TC)StentStentLesionPercutaneous coronary artery Intervention (PCI)Management of unstable anginaTo relieve pain or discomfort (nitroglycerin given by iv)Stronger ant

29、iplatelet agent (aspirin, clopidogrel or ticagrelor given on load dosage)Stronger anticoagulation (LMW-heparin, fondaparinux and bivarudin )Stronger lipid lowing (LDL-C 80mg/dl according to The Guide for Chinese UA patient )PCI or CABG Myocardial infarction DefinitionMyocardial infarction occurs whe

30、n the supply of blood and oxygen to an area of heart muscle is blocked, usually by a clot in a coronary artery. Often, this blockage leads to arrhythmias that cause a severe decrease in the pumping function of the heart and may bring about sudden death. If the blockage is not treated within a few ho

31、urs, the affected myocardium will necrosis and be replaced by scar tissue.A less common cause of MI is a severe spasm of the coronary artery that cuts off blood flow to the heart. These spasms can occur in persons with or without CAD. Artery spasm can sometimes be caused by: Taking certain drugs, su

32、ch as cocaine Emotional stress Exposure to cold Cigarette smoking. Symptoms presymptom：debility , chest discomfort , palpitationsymptoms：Chest discomfort. Most myocadial infarctions involve discomfort in the center of the chest that lasts for more than half of hour . The discomfort can feel like unc

33、omfortable pain, pressure, squeezing, fullness. Heart attack pain can sometimes feel like indigestion or heartburn. Discomfort in other areas of the upper body. Can include pain, discomfort, or numbness in one or both arms, the back, neck, jaw, or stomach. general symptom: Cold sweat, feel weak, etc

34、. gastroenteric manifestation May include having nausea and vomiting arrhythmia arrhythmia with debility,dizzy and so on hypotension and shock hypotension with pain. May include breaking out in a cold sweat, feeling light-headed or dizzy. heart failure dyspneasignsGeneral: fever ,abnormal heart rate

35、 and blood pressure, respiratory distress etc.Heart and lung: soft heart sound, gallops, systolic murmurleft ventricular dysfunction; rales and may be extensiving ElectrocardiogramThe ST segment elevation at infarct leads and the Q wave development R wave decrease in amplitude dynamic state: 1 with

36、Q wave:acute phase normal or large T wave(dissymmetry) ST raise obviously,Q wave emerge in 2 days, R wave descendSubacute phase ST descend ,T wave to place upside down or flatchronic phase T wave is to place upside down just like”V” 2 without Q wave: ST descend widespread(except aVR) Q wave to place

37、 upside down 圖片Example 1A 55-year-old man with 4 hours of crushing chest pain.ECG describe ST elevation in the inferior leads II, III and aVF ;reciprocal ST depression in the anterior leads DiagnosisAcute inferior myocardial infarctionExample 2A 63 year old woman with 10 hours of chest pain and swea

38、ting :ECG describeST elevation in the anterior leads V2 V5, I and aVL reciprocal ST depression in the inferior leadsDiagnosisAcute anterior myocardial infarctionBlood testsWhen cells in the heart die, they release enzymes and another markers of myocardial necrosis into the blood. They are called mar

39、kers or biomarkers. Measuring the amount of these markers in the blood can show how much damage was done to heart. Laboratory FindingsMyoglobin test. This test checks for the presence of myoglobin in the blood a relatively early marker, but less specialTroponin test. This test checks the troponin le

40、vels in the blood. It is considered the most accurate blood test to see if a heart attack has occurred and how much damage was done to the heart. later and more specificCK or CK-MB test. creatin kinase and its isoenzyme These tests check for the amount of the different forms of creatine kinase in th

41、e blood. later and more specific lactate dehydrogenase(LDH or LDH1) a delay marker, but presence longer in bloodClinical diagnosisclinical manifestation+ECG or/and creatase&treponin raiseECG alters by degrees or/and creatase&treponin raise creatase&treponin raise+manifestation (independent diagnosis

42、) differential diagnosisangina pectorisacute pericarditispulmonary embolismsurgical abdomendissection of aorta ComplicationDysfunction or rupture of papillary muscleRupture of heartEmbolismVentricular aneurysmPostmyocardial infarction syndrome ManagementGeneral treat resting to give oxygen guardianship alleviate pain attendanceMyocardium protection:Beta blockers to decrease the workload on heart by slowing heart rate and reduce the incidence of ventricular fibrillationAngiotensin-converting enzyme (ACE) inhibitors to lower blood p