CoronaryAtheroscleroticHeartDiseasesAffiliatedHospitalofJiningMedicalCollegeDept.ofCardiacCareUnitGuoxiaDongdong.0321@163.com25/14/2024ContentsAtherosclerosisStableAnginaPectorisAcuteCoronarySyndromeUAandNSTEMIAMI(STEMI)35/14/2024Self-study

VariantAnginaCardiacSyndromeXSilentMyocardialIschemiaMyocardialBridging45/14/2024WhatIsAtherosclerosis?Atherosclerosisisthedescriptivetermforthickenedandhardenedlesionsofthemediumandlargemuscularandelasticarteries.55/14/2024WhatIsCoronaryHeartDisease?65/14/2024CoronaryheartdiseaseatherosclerosisCoronarystenosiscoronaryspasmMyocardialischemia,necrosisIschemicheartdisease75/14/202485/14/2024Atherosclerosis95/14/2024FoamcellFattysteak

atheromatousplaquerupturedplaquesFibrousplaqueEndothelialdamagefirstdecadeThirddecadeForthdecadeAdaptedfromStaryHCetal.Circulation1995;92:1355-1374.mediumdamage5/14/202410Whatdamagedoesatherosclerosiscause?

115/14/2024CommonlocationCoronaryHeartDiseaseCarotidArteryDiseasePeripheralArterialDiseaseChronicKidneyDisease125/14/2024Howdoesatherosclerosisstartandprogress?135/14/2024ElevatedlevelsofcholesterolandtriglyceridesinthebloodHighbloodpressureCigarettesmoking145/14/2024BiologicalprocessesAccumulationofintimalcellssmoothmusclecellsMacrophagesT-lymphocytes155/14/2024BiologicalprocessesProliferatedconnectivetissuematrixcollagenelastic

fibersproteoglycans

165/14/2024Biologicalprocesses3.Accumulationoflipid175/14/2024Atherosclerosis-Hypothesis

HypothesisoflipoproteininfiltrationAggregationofplateletsandthrombosisClonaltheoryTheresponse-to-injuryhypothesis185/14/2024Highbloodpressure,bacterium,virus,toxin,ox-LDL,immunefactor,vasoactivesubstance.Plateletsareactivated,

adhesionandaggregationofplatelets.Lipidoses,growthfactor,proliferationofsmoothmuclecells,collagen,lipolyticenzyme.Response-to-injury

195/14/2024Pathologyandpathophysiology

FattysteakFibrousplaqueComplicatedlesion205/14/2024InitiationofAtherosclerosis

Fattysteakformation215/14/2024InitiationofAtherosclerosis225/14/2024fibrousplaque235/14/2024245/14/2024

255/14/2024ThinCapVulnerablePlaqueThrombusUnstable“ActiveVolcano”ThickCapCalcifiedPlaqueFlow-limitingLesionStableAngina“DormantVolcano”SAPACSpressureorasqueezingpain!!!265/14/2024UnstableandStablePlaques薄的纖維帽炎性細(xì)胞少的平滑肌細(xì)胞內(nèi)皮細(xì)胞不完整巨噬細(xì)胞較厚的纖維帽沒有炎性細(xì)胞泡沫細(xì)胞完整的內(nèi)皮細(xì)胞較多平滑肌細(xì)胞LibbyP.Circulation.1995;91:2844-2850.unstablestable5/14/202428Atherosclerosis

ClinicalstagesAbsenceofsymptomorstageofincubationischemianecrosis(target

organ)fibrosis295/14/2024clinicalmanifestation

GeneralmanifestationAorticatherosclerosisCoronaryarteryatherosclerosisCerebral

atherosclerosisRAatherosclerosisMesentericatherosclerosisPeripheral

arteryatherosclerosis305/14/2024Laboratory

ExaminationLackofsensitiveandspecificmethodsforearlydiagnosisDyslipidemiaX-ray：DSAshowseverityofstenosisDopplerultrasound:bloodflow315/14/2024Laboratory

Examinationradionuclide：detectionofischemiaEchocardiogram：CHDECGandstresstest:CHDAngiography:themostdirectwayIntravascularultrasound,angioscopeCT,MRI325/14/2024Riskfactors

1.Lipiddisorders(Dyslipidemia)Increasedcholesterol:TcandLDL-c,TG,ApoB,Lp(a)Decreasedcholesterol:HDL-capoA2.Hypertension335/14/2024Riskfactors3.DM,MetabolicsyndromeorinsulinresistancesyndromeMorediffuselesionCADequivalent75-80%causeofdeathinadultDMarevasculardiseases:CAD,cerebrovasculardisease,orperipheralvasculardisease345/14/20247yearsincidenceofdeath/non-fatalMI(EastWestStudy)*ThesepatientshadnohistoryofmyocardialinfarctionHaffnerSM,etal.NEnglJMed.1998;339:229–234.05101520253035404550EventsofMIin7yearsNohistoryofMIOMINohistoryofMI*OMInon-diabetics diabetics n=1373 n=1059P<0.001P<0.0014%19%20%45%DM:CADequivalent355/14/2024Riskfactors

4.

Cigarettesmoking：morethrombogenic5.

Familyhistory6.

Aging：>40yrsadults，4/5fatalmyocardialinfarctionoccuredinpatiens>65yrs7.Malegender/postmenopausalstate：male:female=2：1,mendevelopCHD10-15yrsearlierthanwomen8.alcohol9.Others:diet,homocysteine,hemostaticfactorsinflammation/infection365/14/2024

Drugtherapy

anti-platelet：

aspirin,clopidogrel,GPIIb/IIIainhitibor,Dipyridamole,cilostazolLipid-loweringHMG-CoAreductaseinhibitors（statins）375/14/2024DoubtsofpatientsQuest1：Mybloodpressureisonlyabout100/60mmHg,Whygivemehypotensorlotensin?385/14/2024DoubtsofpatientsQuestion2：Myshapeisnotfat,lipidisnothigh,whygivemelipid-loweringdrugs,madeamistake?395/14/2024DoubtsofpatientsQuestion3：Ihavecoronaryheartdisease,thenshouldIdolessactivities

inordertoprotecttheheart?405/14/2024

CoronaryHeartDisease(CHD)

5/14/202441ClinicalTypeSilentmyocardialischemiaAnginapectorisMyocardialinfarctionIschemiccardiomyopathySuddencardiacdeath5/14/202442SilentMyocardialIschemiaDefinedasdocumentedepisodesofischemianotassociatedwithanytypicaloratypicalsymptomsthatamongpatientswithobstructivecoronaryarterydisease.TypeI:myocardialischemiaisdetectedonroutineECG,24hambulatoryECGmonitoring(Holter),etc.butnotexperienceanginaatanytime;TypeII:patientsaremostfrequentlyencounteredinclinicalpractice.Someepisodesofischemiaareassociatedwithchestdiscomfortandotherepisodesareasymptomatic.5/14/202443IschemicCardiomyopathySymptomsofheartfailure,causedbyischemicmyocardialdysfunction,diffusefibrosis,andmultipleinfarction,aloneorincombination.Manifestations:ventriclesenlargement(dominantleftventricle),heartfailureandarrhythmias.5/14/202444SuddenCardiacDeathSCDisnaturaldeathduetocardiaccauses,heraldedbyabruptlossofconsciousnesswithin1houroftheonsetofacutesymptoms.Thetimeandmodeofdeathareunexpected.WHOdefinition:unexpecteddeathwithin6hours.Thisdefinitionincorporatesthekeyelementsofnatural,

rapidandunexpected.OnehalfofSCDduetocoronaryheartdisease，causedbyseverearrhythmias,suchasventricularfibrillationandcardiacarrest.5/14/202445AcuteCoronarySyndromeACSrepresentsaspectrumofconditions.Acuteplaquechangecharacterizedbyplaqueruptureandexposureofsubstancesthatpromoteplateletactivationandthrombingeneration.5/14/202446STABLEANGINAPECTORIS475/14/2024Definition

Acuteandtransientmyocardialischemiaandanoxaemia.Usuallycausedbycoronaryinsufficiencyduringexertion.485/14/2024Characteristicsparoxysmalprecordialsqueezing-likechestpain,behindthemidsternumradiatedtoleftshoulderandupperarmprecipitatedbystressorexertionrelievedrapidlybyrestornitrates495/14/2024

hypoxiaCoronarystenosis(others:aorticvalvedisease,HOCM)+Myocardialoxygendemand（HRXSBP）increased

myocardialhypoxiaacumulationofmetabolicproduct,stimulateC1-5tocausethesensationofchestpain

mechanism505/14/2024inangiographySignificantcoronarylesionwithdiameterstenosis>70%in75%ptsNosignificantstenosisinabout5-10%pts,Ischemiamayberelatedtocoronaryspasmormicrovasculardysfunction.PathologyStableanginapectoris515/14/2024pathophysiology1.MetabolicandelectrophysiologyATPreduced,accumulationofacidsubstancesDysfunctionofionpump(Na+-K+,andNa+-Ca++)Earlydepolarization(STdeviation)2.LVfunctionandhemodynamicsituationLVcontractility,systolicBP,strokevolume,cardiacoutputdecreasedLVEDpressureandvolumeStunningofmyocardiumStableanginapectoris525/14/2024symptom：chestpainlocation

behindorslightlytotheleftofthemidsternumnodefiniteborderlineradiatedtotheleftshoulderandupperarmAtypicallocation:lowerjaw,thebackofneckClinicalmanifestationStableanginapectoris535/14/2024character：tightness,squeezing,burning,pressing,choking,bursting,rarelysharpduration：3－5minsprecipitatingfactor

exertionoremotionalagitationpainrelief:withinseveralminsafterrestorusingnitroglycerinClinicalmanifestationStableanginapectoris555/14/2024PhysicalexaminationincreasedHR,elevatedBPanxietycoolandsweatyskinoccasionally

galloprhythm，transientsystolicmurmurClinicalmanifestationStableanginapectoris565/14/2024

Auxiliaryexamination1.ECG：Resting

ECGECGduringchestpain:ST-Tchangefoundin95%ptsHolter:detectofslientischemiaStresstesting:Criteriaforpositive:STsegmentdepression

0.1mV，last2minscontraindication：AMI,UAP,myocarditis,Hypertension,heartfailure,aorticstenosis,HOCM,severarrhythmia,aorticaneurysmEndofthetest：STor≥0.2mV，APattacks，BP>220mmHg，BPdrop，ventriculararrhythmiaStableanginapectoris575/14/2024StresstestrestExersciseStableanginapectoris585/14/2024

2.Echocardiography:3.Scintigraphyassessment:CandetectfillingdefectofInfarctionarea4.X-rayofheart 5.coronaryangiography：finaldiagnose6.others:IVUSAuxiliaryexaminationStableanginapectoris595/14/2024CoronaryAngiography605/14/2024StableAnginaPectorisDiagnosisChestpainriskfactorsECGevidenceofischemiaduringchestpainangiography615/14/2024Cardiovascular

causesNoncardiaccausesStableAnginaPectorisDifferentialdiagnosis625/14/2024Cardiovascular

cause

MyocardialinfarctionPericarditisAorticdissectionPulmonaryembolismPulmonaryhypertension635/14/2024Noncardiac

cause

PneumoniawithpleurisySpontaneouspneumothoraxMusculoskeletaldisordersHerpeszosterEsophagealrefluxPepticulcer645/14/2024Generaltreatment：riskfactorscontrol2.Drugtherapy3.Coronaryrevascularization:percutaneouscoronaryintervention(PCI)Coronaryarterybypasssurgery(CABG)SVG,IMAGTreatmentStableAnginaPectoris655/14/2024BloodandoxygensupplytotheheartMyocardial

bloodflowMyocardialoxygen

consumption4%oftotal

cardiacoutput

suppliedtothe

myocardium12%oftotalbodyoxygen,

usedatrestby

myocardium5/14/202466CoronaryReserveMyocardial

bloodflow

increasesupto

4times...…tomeet

increased

myocardialoxygen

demand5/14/202467Myocardialoxygen

supplyanddemandO2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2supplyO2demand5/14/202468AimsofmedicaltherapyArterialvasodilatationReducesarterial

resistanceReducesafterloadDecreases

sympatheticdriveReduceheartrate

andcontractileforceReducescardiacworkLVRVDilatationof

coronaryarteriesImprovescoronary

supplyVenodilatationReduces

venousreturnReducespreload5/14/202469antianginalandanti-ischemictherapyDrugtherapyOxygensupplyOxygendemanda.Nitratesb.Betablockersc.Calciumantagonistsd.DrugsimprovingmetabolismStableAnginaPectoris705/14/2024Drugtherapya.Nitratesloweroxygendemand:decreasearteriolarandvenoustone,reducepreloadandafterloadincreasecoronarysupply:CoronarydilatationNitroglycerinIsosorbidedinitrateisosorbide5-mononitrate(long-actingnitrates)StableAnginaPectoris715/14/2024NitratesinanginaReducepreload

through

venodilatationReduceafterloadby

loweringarterialresistanceReduceplateletaggregationIncreasecoronaryperfusion,includingischaemicareasReversalofcoronaryspasm5/14/202472b.?－blockers:reducemyocardialoxygen:reduceHR,myocardialcontractility,BP,theLVwallstressAbslutecontraindications：severbradycardia:high-degreeA-Vblock,SSS,severeunstableLVfailureRelativecontraindications:asthmaandbronchospasticdiseaseperipheralvasculardisease?1-selective：metoprolol,atenolol,bisoprololDrugtherapyStableAnginaPectoris735/14/2024c.Calciumantagonists：Increaseoxygensupply:dilateconduitandresistancevessels,releasespasm,improvemicrovascularfunctionDecreaseoxygendemand:negativeinotropiceffect,decreaseBPAntiplateleteffectd.DrugsimprovingmetabolismDrugtherapyStableAnginaPectoris745/14/2024preventMIanddeaththerapya.antiplateletangents：ASAclopidogrelCilostazolb.Lipid-loweringangents:statinsc.Angiotesin-convertingenzymeinhibitor(ACEI)DrugtherapyStableAnginaPectoris755/14/2024stentingStableAnginaPectoris765/14/2024UnstableAngina(UA)andnon-STEMI775/14/2024ACSNon-STelevationSTelevationUnstableanginaNon-QwaveAMIQwaveAMI*positiveserumcardiacmarkers****##occasionallyvariantanginaAcuteCoronarySyndrome(ACS)785/14/2024PathophysiologyofACS

stableangina UAP&non-Q-wAMI Q-wAMIAngiographicthrombus

0-1% 75% >90%IncreasedFPA/TAT 0-5% 60-80% 80-90%Activatedplatelets 0-5% 70-80% 80-90%Acutecoronaryocclusion 0-1% 10-25% >90%mortality 1-2% 3-8% 6-15%FPA：fibrinopeptideATAT：thrombin-antithrombincomplexesUAandnon-STEMI795/14/2024Occuringatrest(orwithmininalexertion):last>20minsseverandofnew-onset:within1-2months,CCSIIIOccuringwithacrescendopattern:DeteriorationofCCSclassfication,atleastCCSIIIDefinition

UAandnon-STEMIAnginapectorisorequivalentischemicdiscomfortwithatleastoneofthethreefeatures805/14/2024BraunwaldclassificationofunstableanginaSeverity：ClassI：New-onset,oracceleratedsevereanginanorestpainwithin2monthsClassII：Anginaatrest,subacuteanginaatrest(withintheprecedingmonthbutnotwithin48h)ClassIII：Anginaatrest,acute(withinthepreceding48h)UAandnon-STEMI815/14/2024BraunwaldclassificationofunstableanginaClinicalCircumstancesClassA：SecondaryUAPaclearlyidentifiedconditionextrinsictothecoronaryvascularbedthathasintensifiedmyocardialischemia,e.g.anemia,hypotension,tachy-arrhythmiaClassB：PrimaryunstableanginaClassC：Post-infarctionUAP(within2weeksofadocumentedMI)UAandnon-STEMI825/14/2024mechanism：

1.plaqueruptureanderosion,withnonocclusivethrombus2.dynamicobstruction:Vasoconstruction3.progressivemechnialobstruction(rapidlyadvancingorISRfollowingstenting)4.secondaryUAInflammationThrombogenesisUAandnon-STEMI835/14/2024

ECG:Non-STEMI:STdepressionlast>12hrCardiacbiomarkersofmyocardiumdamage:cTnT,cTnICK-MBUAPandnon-STEMICoronaryangiographyAngioscopyandIVUSOtherlaboratorytests845/14/2024Treatment1.Genearlmanagement:rest,oxygen,CCU2.DrugtherapyA.Anti-ischemicdrug:intravenously,orallynitrates

-blockerCalcium

antagnoist:firstchoiceforvariantanginaMorphinesulfateUAandnon-STEMI855/14/2024Treatment

2.Drugtherapy:B.antithrombotictherapya.Anti-plateletAspirin:early,300mgloadingdoseADP-receptorantagonist:clopidogrel300mg-600mgloadingdose,75mg/dGPIIb/IIIareceptorinhibitor:usedinptsplannedtoPCIb.Anticoagulationtherapy:HeparinLowmolecularweightheparin(LMWH)Directanti-thrombindrug:bivalirudin,hirudin

UAandnon-STEMI865/14/2024Treatment2.Drugtherapy:C.othermedicaltherapy