1. Coronary artery disease

2. Ischemic heart disease( coronary artery disease) Includes Stable angina Acute coronary syndromes Sudden cardiac death due to arrythmia Chronic IHD with CHF Acute coronary syndromes include: Unstable angina Non ST elevation MI( NSTEMI) Myocadial infarction with STE(STEMI)

3. Risk factors Non modifiable risk factors: Age Sex Genetics and familial predisposition

4. Modifiable risk factors: Smoking Heavy drinking Diabetes mellitus Hypercholesterolemia and hyperlipidemia Hypertension Obesity and sedentary lifestyle Increased consumption of saturated fats and decreased intake of PUFA Diabetes mellitus Hypertension

5. Pathophysiology coronary arteries are obstructed due to athelesclerotic plaque formation In mild to moderate stenosis(narrowing) of coronary arteries patients are symptomless If >75% of lumen occlusion coronary arteris cannot dilate during increased physiological need T he artery can become partially blocked or narrowed, which reduces the flow of blood to the heart muscle. Reduced blood flow can cause chest pain, called angina pectoris, especially during physical activity or stress

6. Plaque changes are the commonest initiating event in acute coronary syndrome- caused by the digestion of collagen cap of the atheroma by proteinases from macrophages. The exposed thrombogenic lipid and collagen initiate the coagulation cascade, causing thrombotic events This might lead to unstable angina or myocardial infarction

9. Angina pectoris Angina pectoris is a painful or uncomfortable feeling that can occur when the blood supply to heart muscle is decreased.(ischemia) Can be a heaviness,a tightness, a pressureor burning sensation in the central chest The Pain May also be Felt in the shoulder,neck or along the jaw atypical features may be fatigue,nausea or indigestion,shortness of breath, sweating with or without chest pain Most of the time induced by physical activity Subsides once the physical activity is stopped amnd/or nitrates

10. Types of angina Stable angina Unstable angina

11. Stable angina Due to fixed coronary obstruction Symptoms predictable and persistent over time Case-I have been having exertional chest pain for the past 3 months.It is a central chest pain that radiates along the left upperlimb and occurs only if I exert. Walking about 500m will bring about the symptoms.This symptomatology has not changed over the past 3 months

12. Unstable angina Due to dynamic obstruction Symptoms worsening over time Ex-I ve been having exertional chest pain for the past 1 month. Initially I got it with 1km walk and it was progressive over time. Now I get it even walking 10 feet

15. Myocardial infarction –heart attack Coronary vessel undergo complete obstruction due to plaque changes flow ceases in the coronary vessels beyond the occlusion The area of muscle that has either zero flow or so little flow that it cannot sustain cardiac muscle function Ischemia leads to infarction (ischemic cell death) process is called a myocardial infarction.

17. 17 Progression of coronary plaque over time Clinical Findings Acute Coronary Syndromes Sudden Cardiac Death Acute silent occlusive process Angina pectoris Thrombogenic risk factors Atherogenic risk factors Endothelial dysfunction 20 years 60 years Age

18. Clinical features Some can lead to sudden cardiac death Chest pain is the most common symptom of a heart attack. Commonly chest pain radiating to arms, shoulder, neck, teeth, jaw, belly area, or back. Chest pain The pain can be severe or mild. Gastritis like symptoms Heaviness of the chest The pain usually lasts longer than 20 minutes. Rest and nitrrates completely relieve the pain of a heart attack. Symptoms may also go away and come back. Other symptoms of a heart attack include: Anxiety Light-headedness, dizziness Nausea or vomiting Nauseavomiting Palpitations Shortness of breath Sweating, Sweating

19. Some people (the elderly, people with diabetes, and women) may have little or no chest pain. Or, they may have unusual symptoms (shortness of breath, fatigue, weakness). A "silent heart attack" is a heart attack with no symptom

20. Types Subendocardial transmural

21. Subendocardial vs. Transmural Myocardial Infarction Inner 1/3 or 1/2 Extend past territory of one artery Related to incomplete occlusion Non-Q wave Distribution of one artery Related to complete occlusion Q-wave in ECG

25. 25 Complications of MI

26. 26 COMPLICATIONS OF INFARCTION Ventricular Septal Rupture Papillary Muscle Rupture Ventricular Free Wall Rupture Left Ventricular Thrombus

28. Diagnosis ECG-ST depression, T inversion, ST elevation,Q waves,loss of height of R wave Can diagnose type of MI, region affected by the ECG

29. Cardiac markers When heart muscle becomes irritated it may leak chemicals that can be measured in the blood. Levels of myoglobin, CPK, and troponin I and T

30. Treatment –acute Manage acute life threatening problems Oxygen Pain management-morphine Antiplatelet drugs Lipid lowering drugs thrombolysis-drugs or angioplasty Strict bed rest and liquid diet on D1

31. Treatment long term Feeding and physical activities restored gradually Life style modification Angioplasty CABG

32. Prevention is better than cure...