1 Atherosclerosis ISCHEMIC CHEART DISEASE

2 Atherosclerosis ATHEROSCLEROSIS IS THE CHRONIC DISEASE WITH THE LIPID AND PROTEIN ABNORMAL METABOLISMS, WITH THE DISTRUCTION OF LARGE ARTERIES AND AORTA, AND WITH A FORMATION OF ATHEROSCLEROTIC PLAQUES. ATHEROSCLEROSIS IS THE CHRONIC DISEASE WITH THE LIPID AND PROTEIN ABNORMAL METABOLISMS, WITH THE DISTRUCTION OF LARGE ARTERIES AND AORTA, AND WITH A FORMATION OF ATHEROSCLEROTIC PLAQUES.

3 ATHEROSCLEROTIC PLAQUE NORMAL ARTERY ATHEROSCLEROTIC ATHEROSCLEROTIC PLAQUE PLAQUE

4 Atherosclerosis COMMON RISK FACTORS ARE COMMON RISK FACTORS ARE 1 INCREASING AGE 1 INCREASING AGE 2 MALE GENDER 2 MALE GENDER 3 FAMILY HISTORY 3 FAMILY HISTORY 4 GENETIC ABNORMALITIRS 4 GENETIC ABNORMALITIRS

5 Atherosclerosis POTENTIAL CONTROLLABLE RISK FACTORS ARE POTENTIAL CONTROLLABLE RISK FACTORS ARE 1 HYPERLIPIDEMIA 2 HYPERTENTION 3 DIABETES MELLITUS 4 CIGARETTE SMOKING

6 Atherosclerosis OTHER RISK FACTORS ARE OTHER RISK FACTORS ARE 1 OBESITY 2 PHYSICAL INACTIVITY 3 STRESS 4 POSTMENOPOUSAL ESTROGEN DEFICIENCY

7 Atherosclerosis OTHER RISK FACTORS ARE OTHER RISK FACTORS ARE 5 HIGH CARBOHYDRATE INTAKE 6 LIPOPROTEINS 7 HARDENED UNSATURATED FAT INTAKE 8 CHLAMYDIA PNEUMONIA

8 Pathogenesis of Atherosclerosis According to injury hypothesis considers According to injury hypothesis considers atherosclerosis to be a chronic inflammatory atherosclerosis to be a chronic inflammatory Response of the arterial wall initiated by injury:

9 Pathogenesis of Atherosclerosis 1 chronic endothelial injury 1 chronic endothelial injury 2 insudation of lipoproteins [LDL] 2 insudation of lipoproteins [LDL] 3 modification of lipoproteins by oxidation 3 modification of lipoproteins by oxidation 4 adhesion of blood monocytes 4 adhesion of blood monocytes 5 adhesion of platelets 5 adhesion of platelets

10 Pathogenesis of Atherosclerosis 6 migration of smooth muscle cells 6 migration of smooth muscle cells from the media into the intima from the media into the intima 7 proliferation of smooth muscle cells 7 proliferation of smooth muscle cells in the intima in the intima 8 enhanced accumulation of intra and 8 enhanced accumulation of intra and extra cellular lipids extra cellular lipids

11 ATHEROSCLEROTIC PLAQUE The change of the large arterial intima is called atherosclerotic plaque or atheroma The change of the large arterial intima is called atherosclerotic plaque or atheroma atherosclerotic plaque is the intimal thickening with lipid accumulation atherosclerotic plaque is the intimal thickening with lipid accumulation It consists of fibrous cap, necrotic core and fibrous basis. It consists of fibrous cap, necrotic core and fibrous basis.

12 atherosclerotic plaque It has three principle components: It has three principle components: 1 cells –smooth muscle cells, macrophages 1 cells –smooth muscle cells, macrophages other leukocytes other leukocytes 2 Extra cellular matrix- collagen, elastic fibers, proteoglycans proteoglycans 3 Intra cellular and extra cellular lipids

13 There are two types of atherosclerotic plaque There are two types of atherosclerotic plaque 1 vulnerable 1 vulnerable 2 stable 2 stable atherosclerotic plaque

14 atherosclerotic plaque 1 vulnerable 2 STABLE 1 vulnerable 2 STABLE THERE ARE A LOT OF LIPIDS

15 Progress stages of atherosclerotic plaques according to infiltrative theory 1 Prelipidosis 1 Prelipidosis 2 Lipidosis 2 Lipidosis 3 Sclerosis 3 Sclerosis 4 Atheromatosis 4 Atheromatosis 5 Ulceration 5 Ulceration 6 Calcinosis 6 Calcinosis

16 2 stage is called lipidosis aorta aorta Lipid strips

17 3 stage is called sclerosis Artery with atherosclerotic plaque Artery with atherosclerotic plaque Atherosclerotic plaque with sclerosis

18 4 stage is called atheromatosis 6 stage is called calcinosis 4 stage is called atheromatosis 6 stage is called calcinosis Atheromatosis or porridge-like substance substance calcinosis

19 FORMS OF ATHEROSCLEROSIS CEREBRAL ARTERIES INJURY CEREBRAL ARTERIES INJURY CARDIAC ARTERIES INJURY CARDIAC ARTERIES INJURY RENAL ARTERIES INJURY RENAL ARTERIES INJURY AORTA INJURY AORTA INJURY INTESTINAL ARTERIES INJURY INTESTINAL ARTERIES INJURY EXTREMITY ARTERIES INJURY EXTREMITY ARTERIES INJURY

20 ACUTE FORM MAY BE WITH THROMBOSIS OR THROMBOSIS OR EMBOLISM ON ULCERED PLAQUE EMBOLISM ON ULCERED PLAQUE ISCHEMIC INFARCTION CEREBRAL FORM OF ATHEROSCLEROSIS

21 CEREBRAL FORM OF ATHEROSCLEROSIS Acute form may be as Hemorrhage within The brain due to rupture Of atherosclerotic aneurism

22 CEREBRAL FORM OF ATHEROSCLEROSIS Chronic form may be as encephalopathy Chronic form may be as encephalopathy With cerebral atrophy (decreasing memory)

23 RENAL FORM OF ATHEROSCLEROSIS Acute form may be as infarction Acute form may be as infarction Chronic form is called Chronic form is calledAtherosclerotic Nephrosclerosis or Primary contracted kidney

24 Aortic form of atherosclerosis Various forms of aorta lesion

25 Aortic form of atherosclerosis Complications of atherosclerotic plaque connect with its ulceration. There are Complications of atherosclerotic plaque connect with its ulceration. There are Aneurism Aneurism Rupture of atherosclerotic plaque with retroperitoneal hematoma Rupture of atherosclerotic plaque with retroperitoneal hematoma Thrombosis, the most feared complication Thrombosis, the most feared complication Cholesterol or thrombus embolism Cholesterol or thrombus embolism

26 Intestinal form of atherosclerosis Acute form may be as gangrenous necrosis of the intestine Acute form may be as gangrenous necrosis of the intestine Chronic form may be as ischemic enterocolitis Chronic form may be as ischemic enterocolitis

27 Extremity form of atherosclerosis Acute form may be as gangrenous necrosis. Acute form may be as gangrenous necrosis.

28 Extremity form of atherosclerosis Chronic form with muscle atrophy may be as Dejerine's syndrome [chronic peripheral vascular disease] Muscle fiber atrophy Trichrome stain

29 Cardiac form of atherosclerosis Acute form occurs as myocardial infarction Acute form occurs as myocardial infarction or acute ischemic heart disease or acute ischemic heart disease Chronic form consists of chronic forms of ischemic heart disease Chronic form consists of chronic forms of ischemic heart disease

30 ISCHEMIC HEART DISEASE Ischemic heart disease refers to a group of closely related syndromes caused by an imbalance between the myocardial oxygen demand and the blood supply. Ischemic heart disease refers to a group of closely related syndromes caused by an imbalance between the myocardial oxygen demand and the blood supply.

31 ISCHEMIC HEART DISEASE SYNONYMS ARE CORONARY HEART DISEASE AND SYNONYMS ARE CORONARY HEART DISEASE AND CORONARY ARTERY DISEASE CORONARY ARTERY DISEASE A PICK INCIDENCE IS AFTER 50 YEARS IN MEN AND 60 YEARS IN WOMEN A PICK INCIDENCE IS AFTER 50 YEARS IN MEN AND 60 YEARS IN WOMEN 90% OF ALL INCIDENCES ARE CAUSED BY CORONARY ARTERY NARROWING 90% OF ALL INCIDENCES ARE CAUSED BY CORONARY ARTERY NARROWING

32 ISCHEMIC HEART DISEASE Classification is followed Classification is followed Acute types: Acute types: 1 stenocardia (angina pectoris) 1 stenocardia (angina pectoris) 2 sudden cardiac death 2 sudden cardiac death 3 acute coronary insufficiency 3 acute coronary insufficiency 4 myocardial infarction 4 myocardial infarction

33 ISCHEMIC HEART DISEASE Classification is followed Classification is followed Chronic types are as follow Chronic types are as follow 1 gross post infarction cardiosclerosis 1 gross post infarction cardiosclerosis 2 diffused atherosclerotic cardiosclerosis 2 diffused atherosclerotic cardiosclerosis

34 ISCHEMIC HEART DISEASE RISK FACTORS OF ISCHEMIC HEART DISEASE ARE AS FOLLOW RISK FACTORS OF ISCHEMIC HEART DISEASE ARE AS FOLLOW 1 HYPERLIPIDEMIA 1 HYPERLIPIDEMIA 2 SMOKING 2 SMOKING 3 ARTERIAL HYPERTENTION 3 ARTERIAL HYPERTENTION 4 DECREASING OF PHYSICAL ACTIVITY 4 DECREASING OF PHYSICAL ACTIVITY 5 OBESITY 5 OBESITY 6 HIGH CALORIES DIET 6 HIGH CALORIES DIET 7 STRESS 7 STRESS

35 ISCHEMIC HEART DISEASE ETIOLOGY OCCURS IN CORONARY ARTERY LUMEN: ETIOLOGY OCCURS IN CORONARY ARTERY LUMEN: 1 ATHEROSCLEROTIC STENOSIS 2 CORONARY ARTERY THROMBOSIS 3 CORONARY ARTERY EMBOLISM 4 CORONARY ARTERY SPASM FOR A LONG TIME

36 The general role is played by local atherosclerotic plaque 75% reduction blood suplay is followed by atherosclerotic plaque in the lumen of coronary arteries. 75% reduction blood suplay is followed by atherosclerotic plaque in the lumen of coronary arteries.

37 Thrombosis of coronary artery occurs in 90% with transmural infarction Occlusive thrombus RecurrentTransmural infarction infarction

38 Sources of Thromboembolism occurs from 1 cardiac mural thrombus on endocardium covering 1 cardiac mural thrombus on endocardium covering transmural or subendocardial infarction transmural or subendocardial infarction 2 mural thrombus on atherosclerotic plaque of aortic sinus closed to coronary artery mouth 2 mural thrombus on atherosclerotic plaque of aortic sinus closed to coronary artery mouth

39 PROLOGGED CORONARY ARTERY SPASM Reperfusion of the myocardium leads to added perfuse as reversible then irreversible lesions of the myocardium. Reperfusion of the myocardium leads to added perfuse as reversible then irreversible lesions of the myocardium. Increased myocardial oxygen demand with functional overexertion may also contribute to the development of myocardial ischemia. Increased myocardial oxygen demand with functional overexertion may also contribute to the development of myocardial ischemia.

40 Stages of myocardial infarction 1 ischemic stage 1 ischemic stage 2 necrosis 2 necrosis 3 scarring 3 scarring

41 MYOCARDIAL INFARCTION This is an early acute myocardial infarction This is an early acute myocardial infarction less then 1 day less then 1 day

42 MYOCARDIAL INFARCTION This is an acute myocardial infarction of several day’s duration This is an acute myocardial infarction of several day’s duration

43 MYOCARDIAL INFARCTION The granulation tissue seen here is most prominent from 2 to 3 weeks following onset of infarction. The granulation tissue seen here is most prominent from 2 to 3 weeks following onset of infarction. Scar formation by 8 week Scar formation by 8 week

44 Classification of myocardial infarction According to the time: According to the time: 1 primary 1 primary 2 reccurent (within 6 weeks after primary) 2 reccurent (within 6 weeks after primary) 3 second (after 6 weeks from primary) 3 second (after 6 weeks from primary)

45 Classification of myocardial infarction According to the location: According to the location: 1 anterior and apical left ventricle 1 anterior and apical left ventricle 2 anterior intraventricle septum 2 anterior intraventricle septum 3 posterior wall and posterior third of the 3 posterior wall and posterior third of the intraventricle septum intraventricle septum 4 lateral wall 4 lateral wall 5 papillary muscles 5 papillary muscles 6 enlarge infarct with lesion two or more wall and even right ventricle lesion. 6 enlarge infarct with lesion two or more wall and even right ventricle lesion.

46 Classification of myocardial infarction According to wall thickness of left ventricle According to wall thickness of left ventricle 1 transmural infarction 2 subendocardial infarction 3 mural one 4 subepicardial one

47 COMPLICATIONS OF THE INFARCTION 1Papillary muscle dysfunction 1Papillary muscle dysfunction 2Papillary muscle rupture 2Papillary muscle rupture 3External rupture of the infarction 3External rupture of the infarction 4Rupture of the ventricle septum 4Rupture of the ventricle septum 5Mural thrombosis 5Mural thrombosis 6Acute fibrinous pericarditis 6Acute fibrinous pericarditis 7Ventricle aneurisms (acute, chronic) 7Ventricle aneurisms (acute, chronic)

48 The causes of death 1 Cardiac arrhythmias 1 Cardiac arrhythmias 2 Cardiogenic shock 2 Cardiogenic shock 3 Left ventricle failure 3 Left ventricle failure 4 Rupture of wall, septum, papillary 4 Rupture of wall, septum, papillary muscle muscle 5 Thromboembolism within artery 5 Thromboembolism within artery blood stream blood stream

49 COMPLICATIONS OF THE INFARCTION Aneurisms of left ventricle Aneurisms of left ventricle Acute aneurism with mural thrombus Chronic aneurism

50 COMPLICATIONS OF THE INFARCTION Rupture of cardiac wall in Rupture of cardiac wall in the infarction zone with Hemopericardium and the infarction zone with Hemopericardium and heart tamponade heart tamponade

51 THE END