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 Atherosclerosis is most common cause of coronary artery disease (CAD).  Atherosclerosis can affect one or all three major coronary arteries i.e. LAD, Left circumflex, right coronary artery. 2

What is Atherosclerosis?  It is type of arteriosclerosis or hardening of arteries.  In Atherosclerosis, there is formation of fibro fatty lesions in the intimal lining of the large and medium sized arteries such as aorta and its branches, coronary arteries and cerebral arteries. 3

 Major risk factor is hypercholesteremia.  Hypercholesteremia can be due to 1. Constitutional factors 2. Life style 1. Constitutional factors (can not be changed) such as - increasing age - male gender - family history of premature coronary artery disease 4

2. Life style - Factors can be modified such as - obesity - hypertension - hyperlipidaemia - diabetes mellitus - cigarette smoking 5

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 We will see the normal structure of artery and development of atherosclerosis. 7

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 Development of atherosclerotic lesion is a progressive process involving 1. Endothelial cell injury 2. Migration of inflammatory cells 3. Smooth muscle proliferation and lipid deposition 4. Development of atheromatous plaque with a lipid core 10

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 These maybe 1. Stable or fixed plaque – causes stable angina 2. Unstable plaque – which can rupture and can cause platelet adhesion and thrombus formation and can cause unstable angina and myocardial infarction 14

Why plaque rupture occurs?  It maybe spontaneous or triggered by change in blood flow and vessel tension due to - sympathetic activity - increased BP - heart rate - force of cardiac contraction  These factors may disrupt the plaque. 15

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 It is divided into 1. Chronic ischemic heart disease i. Chronic Stable Angina ii. Variant or Vasospastic Angina also called prinzmetal Angina 2. Acute coronary syndrome i. Unstable angina ii. Myocardial infarction 18

 Coronary Artery Disease – two types 1. Chronic Stable Angina 2. Variant or Vasospastic Angina also called prinzmetal Angina 19

 There is chest pain or pressure sensation or discomfort due to transient myocardial ischemia.  Pain in angina is usually described as constricting, squeezing or suffocating sensation.  Pain is located in sub-sternal area or pre- cordial area of chest.  Pain may radiate to left shoulder, jaw, left arm (inner side) or epigastric region. 20

 Pain is associated with fixed coronary obstruction, usually pathology is atherosclerosis.  Stable Angina is provoked by exercise, emotional stress and is relieved within minutes (5-10mins) by rest or use of nitroglycerine sublingually.  Precipitating factors for pain - physical exertion - exposure to cold - emotional stress 21

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 Variant angina is due to spasm of coronary artery.  Cause is not completely understood but maybe due to - Endothelial dysfunction - Hyperactive sympathetic response - Defective handling of Calcium by vascular smooth muscle - Altered Nitric acid production 23

 Variant Angina occurs at rest or with minimal exercise (stable angina occurs at exercise).  ECG shows Transient ST-elevation. 24

Diagnosis and Treatment  Take detail history of pain (rule out non coronary causes e.g. esophageal reflux or musculo skeletal disorder)  Look for risk factors e.g. hypertension, DM, obesity, hyperlipidemia, smoking  Laboratory test - Noninvasive studies - Invasive studies 25

Noninvasive Test  ECG  X-ray chest  Exercise stress test  Echo cardiography  Nuclear imaging studies  CT and MRI Invasive Test  Coronary Arteriography 26

Treatment 1. Non-pharmacological 2. Pharmacological 3. Coronary intervention 27

Treatment - Non-pharmacological  Life style modification  Stop smoking  Stress reduction  Regular exercise  Weight reduction if obesity  Decrease dietary intake of cholesterol  Avoid cold (it produces vasoconstriction)  If angina – sit down and rest 28

Treatment - Pharmacological  Nitrates  Beta-blockers  Calcium channel blockers  Aspirin 29

Treatment - Coronary intervention  PCI – Percutaneous Coronary Intervention i.e. -Angioplasty -Stent - Surgery Coronary artery bypass graft (CABG) Surgery is indicated in patient with double or triple vessel disease 30

 ACS includes - unstable angina - acute myocardial infarction - ACS is classified based on presence or absence of ST-segment elevation on the ECG 31

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- Serum biomarkers are used to determine whether Myocardial infarction has occurred - Serum makers done in ACS are -- Cardiac Troponin I [TnI] & Troponin T (TnT) -- Myoglobin -- Creatinine Kinase MB (CK-MB) - As myocardial cell become necrotic in MI, their intracellular content diffuse in interstial fluid and blood 33

IMPORTANT  Troponin I and Troponin T are the most sensitive and highly specific for myocardial infarction 34

 Pain in unstable angina occurs at rest or with minimal exertion  Pain lasts for more than 20mins  Unstable angina is risk for MI  Serum markers are not increased usually. 35

 MI is also known heart attack.  There is ischemic death of myocardial tissue.  ECG shows ST-elevation  Area affected depends on which coronary artery is blocked  Serum markers are increased 36

Clinical Presentation  Chest pain which is sudden and severe, retrosternal  Character of pain – crushing, constricting, suffocating or as some one sitting on the chest  Pain is retrosternal but may radiate to left arm (inner side), neck, or jaw or epigastrium. 37

 Pain and sympathetic stimulation combine to give rise to tachycardia, anxiety, restlessness  Sudden death can occur in Acute MI, within one hour of symptoms  Cause of death ventricular fibrillation, ventricle pump failure. 38

 Relieve pain e.g. Morphine  ECG 12 lead – also monitor ECG  Oxygen  Aspirin – anti-platelet  Nitrates - vasodilator  Anti-coagulent  ACE I IMPORTANT Look for candidates for reperfusion therapy 39

 It includes PERCUTANEUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) with inflatable balloon.  Stent implantation  Stents are of two types - Non-drug eluting - Drug eluting – they provide delivery of anti-platelet agents and decrease the risk of restenosis and their results are better than Non- drug eluting stents. 40

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 Surgery is done to bypass the obstructed coronary blood vessel.  Graft are used from 1. Saphenous vein 2. Internal Mammary artery NOTE – Surgery is done for patients with coronary artery disease who do not respond to medical treatment or not suitable for PCI 42

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