Download - Coronary Artery Disease Andrew C Rankin
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Coronary Artery Coronary Artery DiseaseDisease
Andrew C RankinAndrew C Rankin
Glasgow Royal InfirmaryGlasgow Royal Infirmary
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AsymptomaticAsymptomatic Myocardial Myocardial InfarctionInfarction
AnginaAngina
UnstableUnstableanginaangina
Coronary Artery DiseaseCoronary Artery Disease
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Atherosclerosis TimelineAtherosclerosis TimelineFoamFoamCells Cells
FattyFattyStreak Streak
IntermediateIntermediateLesion Lesion AtheromaAtheroma
FibrousFibrousPlaquePlaque
ComplicatedComplicatedLesion/Lesion/RuptureRupture
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
From FirstDecade
From ThirdDecade
From FourthDecade
Endothelial DysfunctionEndothelial Dysfunction
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Risk Factors for Atherosclerotic Disease
Hoeg JM. JAMA. 1997;277:1387–1390.
Non-modifiable
AgeFamily historySex
Modifiable
Cigarette smokingDiabetes mellitusHyperlipidemiaHypertensionObesityPhysical inactivity
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Right Coronary Artery
Posterior Descending Artery
Left Main Coronary Artery
Diagonal Artery
Left Anterior Descending Artery
Coronary arteriesCoronary arteries
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Coronary AngiographyCoronary Angiography
Left coronary arteryLeft coronary artery
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Coronary AngiographyCoronary Angiography
Right coronary arteryRight coronary artery
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JapanFrance
SpainPortugal
MexicoItaly
GreeceLuxembourg
NetherlandsCanada
AustraliaGermany
AustriaUSA
Sweden
DenmarkNorway
PolandUK
FinlandRomania
IrelandCzech Republic
HungaryLithuania
Russian FederationLatvia
0200400600800 200 4001000
Death rates from CHD, (per 100,000) men and women aged 35-74, 1994, selected countries
men
women
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PP
RR
SS
T waveT wave
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Mechanisms of Action of Mechanisms of Action of Anti-Anginal DrugsAnti-Anginal Drugs
Improve Blood SupplyImprove Blood Supply• Coronary VasodilatationCoronary Vasodilatation
Reduce Cardiac WorkloadReduce Cardiac Workload• Slow Heart RateSlow Heart Rate• Reduce Force of ContractionReduce Force of Contraction• Reduce Pre-load / After-loadReduce Pre-load / After-load
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AntianginalsAntianginals Adalat LAAdalat LAAdipine MRAdipine MRAdizem-XLAdizem-XLAngiopine MRAngiopine MRAngitil SRAngitil SRBeta-AdalatBeta-AdalatBeta-PrograneBeta-PrograneBetalocBetalocBetimBetimBlocadrenBlocadrenBritiazimBritiazimCardeneCardeneCardilate MRCardilate MRCedocardCedocard
CoractenCoractenCordiloxCordiloxCorgardCorgardCoro-NitroCoro-NitroDeponitDeponitDilzem SRDilzem SRElantan Elantan LALAEmcorEmcor
GlytrinGlytrinIkorelIkorelImdurImdurInderal LAInderal LAIsib 60XLIsib 60XLIsmoIsmo
IsoketIsoketIsordilIsordilIstinIstinLopresorLopresorMCR-50MCR-50MinitranMinitranMonitMonitMono-CedocardMono-CedocardMonocorMonocorMonomaxMonomaxMyocardolMyocardolNitro-DurNitro-DurNitrocineNitrocineNitrolingualNitrolingual
NitronalNitronalPercutolPercutol
Probeta LAProbeta LASectralSectralSecuron SRSecuron SRSlow-TrasicorSlow-TrasicorSlozemSlozemSorbichewSorbichewSorbidSASorbidSASorbitrateSorbitrateSuscardSuscardSustacSustac
TenifTenifTenorminTenormin
Tildiem LATildiem LATotamolTotamolTrandateTrandateTransidermTransidermTrasicorTrasicorUniverUniver
ViskenVisken
EucardicEucardic
IsocardIsocard NitrominNitromin
PlendilPlendilPosicorPosicor
Syscor MRSyscor MR
Viazem XLViazem XL
Tensipine MRTensipine MR
Drug Therapy for AnginaDrug Therapy for Angina
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Drug Therapy for AnginaDrug Therapy for AnginaBeta-blockersBeta-blockers CalciumCalcium NitratesNitrates KK++ Channel Channel
AntagonistsAntagonists ActivatorActivatorAcebutolol Acebutolol AtenololAtenololBisoprololBisoprololCarvedilolCarvedilolLabetololLabetololMetoprololMetoprololNadololNadololOxprenololOxprenololPindololPindololPropranololPropranololTimololTimolol
II VerapamilVerapamil
IIII AmlodipineAmlodipineFelodipineFelodipineNicardipineNicardipineNifedipineNifedipineNisoldipineNisoldipine
IIII DiltiazemDiltiazem
GTNGTN
IsosorbideIsosorbideDinitrateDinitrate
IsosorbideIsosorbideMononitrateMononitrate
NicorandilNicorandil
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PCI / PTCA = AngioplastyPCI / PTCA = Angioplasty
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Coronary stentsCoronary stents
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Acute Coronary Acute Coronary SyndromesSyndromes
Acute Myocardial InfarctionAcute Myocardial Infarction Unstable anginaUnstable angina
• Rest painRest pain• Crescendo anginaCrescendo angina• New onset anginaNew onset angina
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Role of Platelets in Thrombus Formation
in Acute Ischemic Events
MIMI
StrokeStroke
Vascular Vascular DeathDeath
ThromboticThromboticOcclusionOcclusion
AtheroscleroticAtheroscleroticVesselVessel
LipidCore
PlaquePlaqueRuptureRupture
Platelet Adhesion,Platelet Adhesion,Activation, and Activation, and
AggregationAggregation
ThrombusThrombusFormationFormation
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ST depressionST depression
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ST elevationST elevation
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0 6 12 18 24 2 3 4 5 6 7 8 9 10
RE
LA
TIV
E C
ON
CE
NT
RA
TIO
N
DaysHours
TIME AFTER INFARCT
Normal
TroponinMyoglobin
CK, ASTLDH
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Complications of Acute MI
Acute MIAcute MIExpansion / AneurysmExpansion / Aneurysm RV InfarctRV Infarct
PericarditisPericarditis
MechanicalMechanical Mural ThrombusMural Thrombus
ArrhythmiaArrhythmia
Heart FailureHeart Failure
Extension / IschemiaExtension / Ischemia
LVRV
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ISIS-2.Lancet 1988;11:349–360
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Acute coronary syndromeAcute coronary syndrome
No ST elevationNo ST elevationST elevationST elevation
Thrombolytic therapyThrombolytic therapyPCIPCI
??
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Thrombolysis for ACS Thrombolysis for ACS without ST elevation?without ST elevation?
It doesn’t work!It doesn’t work!e.g. Fibrinolytic Therapy Trialist (1994)e.g. Fibrinolytic Therapy Trialist (1994)
• 3563 patients with suspected AMI• ST segment depression• Mortality 15.2% vs 13.8%
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GUSTO IIbGUSTO IIb
0%
2%
4%
6%
8%
10%
0 30 60 90 120 150 180
Days from Randomization
Mo
rtal
ity
T-wave inversion
ST-segment depression
ST-segment elevation
0%
2%
4%
6%
8%
10%
0 30 60 90 120 150 180
Days from Randomization
Mo
rtal
ity
T-wave inversion
ST-segment depression
ST-segment elevation
T-wave inversionT-wave inversion
ST ST
ST ST
P 0.001P 0.001
ECG and outcome in ACSECG and outcome in ACS
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1.01.7
3.4 3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/ml)
1.01.7
3.4 3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/ml)
Mo
rtal
ity
at 4
2 D
ays
Mo
rtal
ity
at 4
2 D
ays
831831 174174 148148 134134 5050 6767
%%%%
%%%%
%%
%%
Troponin level and mortality in ACSTroponin level and mortality in ACS
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Myocardial infarction redefinedMyocardial infarction redefinedWHO definition: (2 of 3)WHO definition: (2 of 3)
• Typical symptoms (chest pain)
• Typical ECG changes (Q waves)
• Enzyme riseESC/ACC redefinition 2000ESC/ACC redefinition 2000• Troponin rise, with one of:• Chest pain• ECG changes (Q waves or ST segment)• PCI
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Acute coronary syndromeAcute coronary syndrome
No ST elevationNo ST elevationST elevationST elevation
Chest painChest painPresentationPresentation
WorkingWorkingDiagnosisDiagnosis
Myocardial InfarctionMyocardial Infarction
STEMISTEMI NSTEMINSTEMI
++
++
Unstable AnginaUnstable Angina
--
ECGECG
TroponinTroponin
Final Final diagnosidiagnosiss
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