ischaemic heart disease acute coronary syndromes
DESCRIPTION
ISCHAEMIC HEART DISEASE Acute Coronary Syndromes. JD Marx Department of Cardiology University of the Free State. Acute Coronary Syndromes. PATHOPHYSIOLOGY Intermittent, partial or total occlusion of coronary artery responsible for acute myocardial ischaemia Several factors play a role . - PowerPoint PPT PresentationTRANSCRIPT
ISCHAEMIC HEART DISEASE Acute Coronary Syndromes
JD MarxDepartment of Cardiology
University of the Free State
Acute Coronary SyndromesPATHOPHYSIOLOGY
Intermittent, partial or total occlusion of coronary artery responsible for acute myocardial ischaemia
Several factors play a role
Acute Coronary SyndromesPATHOPHYSIOLOGY
Unstable angina MI Ischemic stroke/TIACritical leg ischemiaIntermittentclaudicationCV death
Atherosclerosis
Stable angina intermittent claudication
Thrombosis
MI=myocardial infarction ACS=acute coronary syndromes TIA=transient ischemic attack CV=cardiovascular
ACS
Acute Coronary Syndromes
Vulnerable plaque present in most patients Culprit lesions most often a low grade lesion
1. Atherosclerotic Lesions in ACS
Acute Coronary SyndromesMultiple Unstable Lesions
Acute Coronary Syndromes
0%5%
10%15%20%25%30%35%40%45%
MACROPHAGES T LYMPHOCYTES
7%
25%29%
6%
29%
43%
RECU
RREN
T UA
P
2. Inflammation in ACS
Acute Coronary Syndromes
Thrombosis on ulcerated or ruptured plaque plays pivotal role
› Platelet Thrombus
› Fibrin Thrombus
3. Thrombus in ACS
Platelet Adhesion
Tissue factor, vWF
COLLAGEN I
GP lb- IX
GP IIb - IIIa
GP Ia - IIa
Plaque rupture, endothelial damage, fibrous cap erosion
Platelet Activation and Aggregation
PlateletThrombin
ADP
Thromboxane A2
Epinephrine
Serotonin
Collagen
PAR-1
PAR-4P2Y1
P2Y12
TXA2-R
5HT2AAnionicphospholipidsurfaces
GP IIbGP IIIa
GP VI
Platelet
GP IIIaGP IIb
Fibrinogen
GP Ia
Platelet Aggregation
Flowingdisc-
shapedplatelet
Rollingball-shaped
platelet
Hemisphere-shapedplatelet
Spreadingplatelet
FIRM, BUT REVERSIBLEADHESION
IRREVERSIBLEADHESION
Scanning electron micrograph of discoid, dormant platelets
Activated, aggregating platelets illustrating fibrin
strands
Platelet Thrombus
Thrombus on Plaque Rupture
Microembolization in Unstable Angina
Courtesy of C. Michael Gibson, MS, MD, Director TIMI Data Coordinating Center, Brigham & Women’s Hospital, Associate Chief of Cardiology, Interventional Cardiologist, Beth Israel Deaconess Medical Center, Harvard Medical School.
Acute Coronary Syndromes
Thrombosis on ulcerated or ruptured plaque plays pivotal role
› Platelet Thrombus
› Fibrin Thrombus
3. Thrombus in ACS
Fibrin Thrombus
Can play an important etiological role
Acute Coronary Syndromes4. Coronary Artery Spasm in ACS
Acute Coronary SyndromesPATIENT WITH MYOCARDIUM AT RISK
CLINICAL PRESENTATION
Unstable Angina Pectoris› Angina of recent onset ( 1 month )› Angina at rest› Worsening angina› Early post infarction angina
Non ST-segment elevation myocardial infarction› Cardiac enzymes elevated e.g. troponins,CK, MB-CK
ST-segment elevation myocardial infarction› Normal progression to Q-wave infarction
Acute Coronary SyndromesUnstable Angina Pectoris &
Non ST-segment elevation infarctionTREATMENT
1. Medical Stabilizationa) General
i. Hospitalizationii. Monitor as appropriateiii. Pain reliefiv. Sedation as necessary Identify and treat
precipitating factors e.g. anaemia, tachiarrhythmias
Acute Coronary SyndromesTREATMENT
b) Drugsi. Antithrombotic • Antiplatelet e.g.. Aspirin• Anticoagulant e.g.. Heparin
ii. Antianginal• Nitrates• β-Blockers• Calcium Antagonists
iii. Disease Modifying Drug• Statins• ACE Inhibitors
Acute Coronary SyndromesTREATMENT
2. Coronary AngiographyEvaluate coronary anatomy
Depending on clinical and anatomic findings an appropriate
long term treatment is determined.
Acute Coronary SyndromesLONG TERM TREATMENT
Medical therapy
Coronary angioplasty
Coronary artery Bypass Graft surgery
Diffuse Disease
MAHOMED
Right Coronary Artery
Before PTCA After PTCA
Stenting
LAD BEFORE STENT LAD AFTER STENT
Multi vessel disease: Surgery
Patent LIMA
Patent SVG
Thank you