1. ISCHAEMIC HEART DISEASE STABLE ANGINA & ACUTE CORONARY SYNDROME (ACS)
By Dr. Zahoor

2. ISCHAEMIC HEART DISEASE (IHD)
Why myocardial ischaemia occurs?
Myocardial Ischaemia occurs when there is less supply of oxygen to the heart
Less supply of oxygen may be due to decreased blood flow because of coronary artery disease

3. Diagram of coronary circulation

4. ISCHAEMIC HEART DISEASE (IHD)
Coronary artery disease may be due to
- Atheroma
- Thrombosis
- Embolus
- Spasm
- Coronary ostial stenosis

5. ISCHAEMIC HEART DISEASE (IHD)
Coronary Artery Disease (cont)
Decrease in oxygenated blood flow to coronary artery due to
- Anaemia
- Carboxyhaemoglubinaemia
- Hypotension
Increased demand of oxygen due to
- increase cardiac output e.g. Throtoxicosis
- myocardial hypertrophy e.g. Hypertension,
Aortic Stenosis

6. ISCHAEMIC HEART DISEASE (IHD)
Myocardial Ischemia occurs most commonly due to obstructive coronary artery disease (CAD) in the form of coronary Atherosclerosis
CAD is the largest cause of death in UK and many parts of the world
In 2009 in UK, 1:5 male and 1:8 female death were from coronary artery disease
Sudden death can occur

7. ISCHAEMIC HEART DISEASE (IHD)
We will study the process of Atherosclerosis in coronary artery, which causes CAD.
Coronary Atherosclerosis is characterized by accumulation of lipid, macrophages and smooth muscle cells in the intimal plaques in large and medium size coronary arteries
Process of Atherosclerosis
- Endothelial injury
- Accumulation of lipoprotein (LDL)
- LDL are taken by macrophages
- Formation of foam cells – macrophages which have
taken LDL
- Proliferation of smooth muscle cell

8. ISCHAEMIC HEART DISEASE (IHD)
Formation of Plaque
- Proliferation of smooth muscle cells with collagen formation, lipid deposition, macrophages, inflammatory cells, endothelial cell proliferation all make fibro lipid plaque
- Plaque may be
stable
unstable (can rupture)
- Plaque can obstruct the blood vessel
- Plaque can undergo thrombosis

9. ISCHAEMIC HEART DISEASE (IHD)
Coronary artery disease (CAD) gives rise to
1. Stable angina
2. Acute coronary syndrome
- Unstable angina
- Non ST elevation myocardial infarction
(NSTEMI)
- ST elevation myocardial infarction (STEMI)

10. Mechanism for development of thrombosis on plaque

11. ISCHAEMIC HEART DISEASE (IHD)
Risk Factors
Fixed IHD risk factors (that can not be changed)
Age – CAD increases with age
Male sex – higher incidence than premenopausal women
Positive family history

12. ISCHAEMIC HEART DISEASE (IHD)
Risk Factors (Potentially changeable risk factors)
Hyperlipidaemia
Hypertension
Diabetes mellitus
Cigarette smoking
Diet and obesity
Lack of exercise
It is recommended that adult should do a minimum of 30mins of moderate activity e.g. Brisk walking, cycling on 5 days of the week

13. ISCHAEMIC HEART DISEASE (IHD)
Risk factors for Coronary Artery Disease

14. ISCHAEMIC HEART DISEASE (IHD)
Primary and Secondary Prevention
Primary Prevention
- It is prevention of atherosclerotic disease process
Secondary Prevention
- It is treatment of atherosclerosis that is treatment of disease or its complication

15. ISCHAEMIC HEART DISEASE (IHD)
Important Point
Blood Pressure should be maintained below 140/90 mmHg (in Diabetes, BP 130/80 mmHg)
Serum cholesterol should be below 4.0 mmol/L
HDL should be more than 1 mmol/L
LDL should be less than 2 mmol/L

16. Stable Angina

17. ISCHAEMIC HEART DISEASE (IHD)
Stable Angina
The most common symptom associated with angina is central chest pain on exertion
Pain of angina pectoris and myocardial infarction is due to myocardial hypoxia
Pain in angina is retrosternal, heavy, tight or gripping, with radiation to left arm, neck, jaw , epigastrium.
Pain last for 2-10 minute, may be mild or severe

18. ISCHAEMIC HEART DISEASE (IHD)
Pain is provoked by physical exertion, after meal, cold, windy weather, excitement
Pain is relieved by rest or sublingual nitrates ( GTN )

19. Anginal Pain - Radiation

20. ISCHAEMIC HEART DISEASE (IHD)
Diagnosis of angina is largely based on clinical history

21. TYPES OF ANGINA Stable angina – pain related to exertion
Unstable angina – pain occurs at rest, it is part of acute coronary syndrome and we will discuss later with acute coronary syndrome
Refractory angina – when anginal pain is not controlled by medical therapy, patient is having severe coronary disease

23. TYPES OF ANGINA (cont) Variant (Prinzmetal’s) angina
- Angina usually at rest
- It is due to coronary artery spasm
- More in women
- There is ST elevation on ECG during pain
5. Cardiac syndrome X
- Patient has history of angina, positive exercise test but on angiography coronary arteries are normal. Prognosis is good.

24. STABLE ANGINA Examination No abnormal finding in angina Look for
- Anaemia
- Throtoxicosis
- Hyperlipidaemia (Xanthelasma, Tendon
Xanthoma)
- Check blood pressure for hypertension
- Examine CVS, exclude aortic stenosis as
possible cause of angina

25. STABLE ANGINA (cont) Investigations
ECG – 12 lead ECG is normal between attacks
During attack, transient ST-depression, T-wave inversion may appear
Cardiac enzymes – Troponin T and Troponin I normal
Exercise (Stress) ECG – ST- depression of 1 mm is taken as positive test
CT – coronary angiography

26. STABLE ANGINA (cont) Investigations (cont) Functional imaging – SPECT
Stress Echocardiography
Stress Magnetic resonance imaging (MRI)
Cardiac catheterization
Note – SPECT – Single Photon Emission Computed Tomography – it is scan of heart, non invasive nuclear imaging test after radioactive tracer injection given IV

27. STABLE ANGINA (cont) Management of Stable Angina
Inform the patient about the nature of disease and reassure that prognosis is good
Annual mortality < 2%
Treat underlying problem e.g. anemia or hyperthyroidism

28. STABLE ANGINA (cont) Management of Stable Angina (cont)
Manage DM, hypertension if present
Look for risk factors e.g. smoking, obesity, hypercholesterolaemia, advice and treat
Regular exercise should be encouraged

29. STABLE ANGINA (cont) Pharmacological therapy
Vasodilator – GTN (Glyceryl Trinitrate 0.3-1mg sublingual)
Isosorbide mononitrate – 10-60mg orally twice daily
Beta Blocker
Atenolol (Tenormin) mg daily
Bisoprolol (Concor) mg/day
Beta blocker decrease heart rate, decrease BP, and decrease myocardial O2 demand

30. STABLE ANGINA (cont)
Pharmacological therapy (cont) 3. Calcium channel blocker -Verapamil – mg three times per day - Diltiazem – mg three times per day - Amlodipine (mainly vasodilator) – 5-10mg per day Verapamil and Diltiazem decrease force of cardiac contraction and inhibit cardiac conductive tissue, therefore, they are contraindicated in severe bradycardia, left ventricular failure, second or third degree heart block - Side effect – Verapamil - Constipation

31. STABLE ANGINA (cont) Pharmacological therapy (cont)
Secondary Prevention
Aspirin 75mg daily – it is anti platelet, side effect is GI bleeding
ACE inhibitors – used if hypertension, heart failure.
Statins (Lipitor ) used to reduce total cholesterol to 4mmol/L and LDL to blow 2mmol/L

32. STABLE ANGINA (cont) Revascularization
PCI – Percutaneous Coronary Intervention
It is process to dilate coronary artery stenosis, using inflatable balloon and metallic stent introduced via femoral, radial, or brachial artery

33. Intra Coronary Stent

34. STABLE ANGINA (cont) Revascularization (cont)
Complication – bleeding, hematoma, pseudo aneurysm
Serious Complication
– Acute MI 2%
– Stroke 0.4%
– Death 1%
When metallic Drug – eluting stent are used, patients are advised to take Aspirin, Plavix for 1 year

35. Percutaneous Transluminal Coronary Angioplasty PTCA
A. Right coronary artery (RCA) occluded
B. Soft wire passed
C. Balloon is inflated to dilate stenosis
D. RCA reopened

36. STABLE ANGINA (cont) Coronary Artery Bypass Grafting (CABG)
Autologus veins or arteries are anastomosed
Saphanous vein or internal memory artery are used
Operative mortality < 1%

37. Relief of Coronary Obstruction By Surgical Techniques

38. Algorithm for Management of Patient’s with Stable Angina

39. ACUTE CORONARY SYNDROME

40. Patient with chest pain

41. ACUTE CORONARY SYNDROME (ACS)
ACS is term used for
1. Unstable Angina
2. Myocardial infarction [MI] – NSTEMI
3. Myocardial infarction [MI] – STEMI
Unstable Angina occurs at rest or minimal exertion in absence of myocardial damage.
MI symptoms occur at rest and there is evidence of myocardial damage, demonstrated by increased level of cardiac Troponin or creatinine kinase-MB.
IMPORTANT – Troponin is more specific

42. UNSTABLE ANGINA
There is partial/intermittent occlusion of coronary artery
Chest pain occurs at rest and lasts for more than 20 minutes
ECG – ST depression, T wave changes (T inversion)
Cardiac enzyme – Troponin T & I normal Because No myocardial damage has occurred

43. NSTEMI Chest pain occurs at rest and lasts for more than 20 minutes
ECG – ST depression, T wave changes (T inversion)
Cardiac enzyme – Troponin T & I are increased Because myocardial damage has occurred

44. STEMI
Severe Chest pain occurs at rest and lasts for 30 minutes to 1 hour
ECG – ST elevation, T wave changes , later Q wave appear
Cardiac enzyme –Troponin T & I are increased and CK-MB increased

45. STEMI (cont) IMPORTANT
In STEMI, there is severe damage to the myocardium due to occlusion of blood flow in the coronary artery that causes death of myocardial tissue
Sudden death from ventricular fibrillation or asystole within 1 hour can occur.
IMPORTANT
Thrombolytic therapy is given in STEMI
Thrombolytic therapy is NOT GIVEN IN UNSTABLE ANGINA AND NSTEMI

46. NSTEMI & UNSTABLE ANGINA
Investigations and Treatment
High risk patient who are likely to progress to MI require urgent coronary angiography in less than 72 Hours
Who are high risk patient ?
- Patient with persistent angina or recurrent angina with ST changes > 2mm or deep negative T wave changes .
- Clinical signs of heart failure
- Hemodynamic instability
- Life threatening arrhythmias

47. NSTEMI & UNSTABLE ANGINA (Cont)
Patient having high risk score ( CONT )
Increased Troponin
Dynamic ST or T wave changes
Previous MI
PCI within last 6 months
Previous CABG

48. Medical Treatment Unstable Angina &NSTEMIO2
Morphine and anti emetic
Aspirin
Clopidrogrel (Plavix )- anti platelet agent
Enoxaprin- low molecular heparin
Beta blocker
ACE-Inhibitors
Nitrates
Statins eg lipitor

49. ST Elevation MI ( STEMI )
ECG changes in myocardial infarction (STEMI)
Leads Showing ST Elevation
Infarct Site
V2 – V5
Anterior
V1 – V3
Anteroseptal
V4 – V6, I, aVL
Anterolateral
I, aVL
Lateral
II, III, aVF
Inferior
V1, V2(Reciprocal)
Posterior

50. ST ELEVATION MI
COMMENT ON ECG

51. ST elevation in
lead 1 ,aVL, V2, V3 , v4,v5, v6
ANTERO-LATERAL MI

52. STEMI
COMMENT ON ECG

53. ST ELEVATION IN LEAD II,III,aVF
INFERIOR MI

54. Medical Treatment STEMIO2
Morphine and anti emetic
Aspirin
Clopidrogrel (Plavix )- anti platelet agent
Enoxaprin- low molecular heparin
Beta blocker
ACE-Inhibitors
Nitrates
Statins eg lipitor

55. STEMI
PCI
PCI is advised , where facilities are available, when patient presented to hospital in 12 hours of pain.
THROMBOLYSIS
If PCI not availble ( small hospital ) Fibrinolysis (Thrombolysis) is done within 6 hours ( Up to 12 hrs )of STEMI
Drugs used for Thrombolysis are
Alteplase (human tissue plasminogen activator or tPA )
Streptokinase

56. STEMI -COMPLICATIONS Heart failure Myocardial rupture
Ventricular septal defect
Mitral regurgitation due to severe LV dysfunction and dilatatiopn
Papillary muscle dysfunction

57. STEMI – CARDIAC ARRHYTHMIAS
Ventricular tachycardia and ventricular fibrillation
Cardiac arrest
Atrial fibrillation
Conduction defect - common with INFERIOR MI as Rt coronary artery supplies Inferior surface and SA & AV nodes.

58. Post ACS Life style modificatiion
Diet- Omega- 3 fatty acid from fish
Daily walk min daily
Stop smoking
Maintain alcohol consumption in safe limits 21 units/ week
If over weight – reduce weight
Control Hypertension less than 140/90 mmHg , if patient has DM, than BP less than 130/ 90 mmHg
Maintain Hb A1c less than 7% in Diabetic patient

59. CASE HISTORY – A patient with hypertension and chest pain
A 50 year old smoker with hypertension develops central crushing chest pain radiating to his jaw. He has vomited and now feels short of breath. ECG was done which is shown.

61. Questions: What is the diagnosis? a. Posterior MI b. Inferior MI
c. Antrolateral MI
d. Pericarditis
Patient is given Morphine, anti-emetic and aspirin. He is taken immediately to the cardiac cath lab, where he undergoes coronary angiography and stenting to one of the vessels. Which coronary artery is stented?
a. Right
b. Circumflex
c. Diagonal
d. Left anterior descending (LAD)

62. Answers:
Answer to Question 1 : c. Antrolateral MI Answer to Question 2: d. Left anterior descending (LAD)

63. Thank you