2. Coronary Artery Disease Ischemic heart disease

4. 2 coronary arteries branch from the main aorta just above the aortic valve. “No larger than drinking straws, they divide and encircle the heart to cover its surface with a lacy network that reminded physicians of a slightly crooked crown (coronary comes from the Latin coronarius, belonging to a crown or wreath). They carry out about 130 gallons of blood through the heart muscle daily.” (Clark, 119) Blood Supply To The Heart

5. Coronary Artery Disease Coronary artery disease is one of the most common and serious effects of aging. Fatty deposits build up in blood vessel walls and narrow the passageway for the movement of blood. The resulting condition, called atherosclerosis often leads to eventual blockage of the coronary arteries and a “heart attack”. Coronary artery disease is one of the most common and serious effects of aging. Fatty deposits build up in blood vessel walls and narrow the passageway for the movement of blood. The resulting condition, called atherosclerosis often leads to eventual blockage of the coronary arteries and a “heart attack”.

7. “Cardiovascular disease claimed 39.4 percent of all deaths or 1 of every 2.5 deaths in the United States in 2000. CVD was about 60 percent of “total mention mortality.” This means that of over 2,400,000 deaths from all causes, CVD was listed as a primary or contributing cause on about 1,415,000 death certificates.” (American Heart Disease)

9. Since 1900, CVD has been the No. 1 killer in the United States every year but 1918. Nearly 2,600 Americans die of CVD each day, an average of 1 death every 33 seconds. CVD claims more lives each year than the next 5 leading causes of death combined, which are cancer, chronic lower respiratory diseases, accidents, diabetes mellitus, influenza and pneumonia. Almost 150,000 Americans killed by CVD each year are under age 65.

10. Signs and Symptoms None: This is referred to as silent ischemia. Blood to your heart may be restricted due to CAD, but you don’t feel any effects. Chest pain: If your coronary arteries can’t supply enough blood to meet the oxygen demands of your heart, the result may be chest pain called angina. Shortness of breath: Some people may not be aware they have CAD until they develop symptoms of congestive heart failure- extreme fatigue with exertion, shortness of breath and swelling in their feet and ankles. Heart attack: Results when an artery to your heart muscle becomes completely blocked and the party of your heart muscles fed by that artery dies. Signs & Symptoms None Chest Pain Shortness Of Breath Heart Attack

11. can, and does, occur in almost any artery in the body. But in the heart it’s effects can be crucial. “The body depends on a strong pumping heart to circulate life-giving blood, and this includes to the heart muscle itself. If the coronary arteries become blocked, the cardiac muscle begins to fail, and so the blood circulation decreases, which includes the circulation to the heart muscle itself.” (Thibodeau, 494)

13. High blood cholesterol High blood cholesterol High blood pressure High blood pressure Smoking Smoking Obesity Obesity Lack of physical activity Lack of physical activity

14. Screening and Diagnosis StressTestmeasuresblood supply to heart Coronary CoronaryAngiography specificshowscoronaries Narrowing in Sites of Electro-cardiogrammeasureselectrical impulses

20. Cholesterol Diet Liver Cholesterol Metabolism 15%75%

22. Treatment in CHD Patients

29. Economic impact: Despite age adjusted decline in CVD mortality, there is paradoxic increase in economic burden due to: 1) aging population causing actual number of CVD cases to remain stable 2) technologic advances causing more aggressive and extensive treatment

31. Dyslipidemia Better term than hyperlipidemia as it includes the risk of having low HDL Serum total cholesterol (TC) is a composite of: LDL cholesterol- directly related to CVD HDL cholesterol- inversely related to CVD VLDL cholesterol- related to CVD in patients with DM and low HDL Best single predictor for CVD risk is TC/HDL ratio. Ideal ratio is 5 This ratio is also the best predictor of treatment benefits

33. Hypertension Potent risk factor for all CVD and dominant risk factor for stroke. Graded relationship between level of BP and outcomes. SBP rises with age, whereas DBP plateaus in the late middle life and decreases somewhat then. Trials for isolated systolic hypertension have shown benefits for both stroke and CHD

34. Systolic and diastolic hypertension increase the RR for CVD by 1.6 times For combined Systolic and diastolic HTN the RR is 2.0 The risk for CVD is increased even in individuals with “high normal BP” (130-39/85-89 mm Hg)

35. Smoking This habit increases the risk of vascular outcomes by 2 fold. Both, regular and filter cigarettes have same adverse effects. Low tar/low nicotine products have not been shown to reduce the risk Unlike other modifiable risk factors, cigarette smoking can be eliminated entirely Benefits of quitting smoking are dramatic. Risk in ex-smokers falls to near non-smoking levels in 2 yrs.

36. Obesity It contributes independently to CVD risk and also aggravates knownCVD risk factors. Measures of obesity include: BMI Waist: hip ratio.

38. Synergy of risk factors: The CHD death risk in men who smoke, have DBP>90 mm Hg, TC>250 mg/dl, the actual risk is 82/1000 v/s 43/1000 if all the three risk factors are added Thus there is multiplicative effect of multiple risk factorsacting in concert. Also control of one risk factor provides substantial benefit in persons with multiple risk factors

40. (Circulation 1998;97:1837)

42. Clinical presentation of CHD depends on age and gender Women: Angina is most common first CHD event followed by MI Men: MI is the most common first event followed by angina. Sudden cardiac death is not uncommon

43. Acute myocardial infarction (AMI) One of the most common diagnosis in hospitalized patients in industrialized nations Mortality of acute MI is 30% and one-half of these deaths occur before hospitalization Mortality after admission has decreased by 30% in last 2 decades 1 in 25 pts (4%) who survive till hospital discharge die within one year

45. Pathophysiology AMI results when thrombus (occlusive/nonocclusive) develops at the site of ruptured plaque Vulnerable plaque Rupture Coagulation cascadeplatelet adhesion, activationactivation,aggregation Fibrin and platelet clot Coronary occlusion MI

49. STEMI ASA, beta blockers, antithrombin therapy 12 hrs Eligible for Lytic therapy Lytic C/I Not a candidate For reperfusion Persistent symptoms ThrombolysisPrimary PCInoyes Other medical therapyConsider reperfusion (ACEI, nitrates, beta blockers, antiplatelets, antithrombin,statins)

50. Time is muscle

54. Unstable angina/NSTEMI Aspirin, antithrombin, nitrates, GP IIb-IIIa antagonist Betablockers(calcium channel blockers) Assess clinical status High risk/unstableStable (Recurrent ischemia, LV dysfunction Widespread EKG changes, positive enzyme markers) Cardiac catheterizationSevere ischemia Revascularization (PCI/CABG)Medical therapy Stress test yes no

55. Circulation 2004;110:227-239

56. Smoking cessation: In FHS, smoking was found to increase the risk for CAD, stroke, heart failure, and peripheral vascular disease at all levels of blood pressure Smoking cessation in hypertensive patients who smoke 1 ppd was estimated to reduce cardiovascular risk by 35-40% 2-3 yrs after cessation, the risk for CAD declines to that of subjects who have never smoked

57. Lung Health Study Annals of Internal Med, 2005