Coronary Artery Diseases Dr. Tarek

CoronaryPneumonia
Artery Diseases
Medical Department of College of Medicine in 21 September University
: Prepared by
Dr . TAREK AL-SHAIBANI
Angina Pectoris
 Stable Angina Pectoris is the most common

manifestation of CAD manifested as chest
pain , pressure , discomfort that develop
with exertion & relieved with rest .
Pathophysiology
 Symptoms occur when atheromatous plaque

> fixed coronary stenosis > limitation of
blood flow > imbalance bet. Myocardial
Oxygen supply & demand .
Anginal Pain Definition
 Constricting discomfort in the front of the
chest , neck , shoulders , jaw or arms .
 Precipitated by physical exertion .
 Relieved by rest or GTN in about 5 minutes

Anginal Pain Definition
 Pts. With all 3 features have typical angina .
 Pts. With 2 features have atypical angina .
 Pts. With 1 or none feature have non-

anginal chest pain .
Diagnosis
 If pts. Have typical anginal symptoms & a
risk of CAD is greater than 90 % then no
further diagnostic testing is required .
 For pts. With an estimated risk of 10 – 90 %

the following investigations are
recommended :
Exercise ECG
 Exercise testing is no longer recommended.

Exercise ECG Contraindication
 Conduction abnormalities e.g RBBB .
 Resting ECG abnormalities like ST segment

depression of > 1 mm .
 WPWS & those w. ventricular pacing rhythm.
 Those on digoxin .
Coronary angio. indications
 Estimated likelihood of CAD 61 – 90 % .
 Persistent or progressive symptoms while

on optimal medical therapy .
 High risk criteria on non invasive stress test

Functional imaging
 Myocardial perfusion scan with SPECT .
 Dobutamine stress echo .
 Contrast enhanced MR perfusion .
 MR imag. for stress induce wall motion abn.

CT Calcium Scoring
 Estimated likelihood of CAD is 10 – 29 % .

Dobutamine stress echo indica.
 Pts. Who are unable to exercise because of :

* Stroke .
* PVD .
* Arthritis .
Non-atheroscler. angina causes
 Anaemia .
 Thyrotoxicosis .
 Aortic stenosis & Aortic regurgitation .
 HOCM .
Angina Pectoris Management
 Lifestyle changes .
 Medication .
 Percutaneous coronary intervention .
 Surgery .
Risk Factors Modifications
 Smoking cessation .
 Wt. management .
 Daily physical activity .
 Diet modification .
Modifiable Risk Factors Control
 DM .
 Hypertension .
 Hyperlipidemia .
Medical Therapy
 Cardio-protective medications .
 Anti-anginal medications .
Cardio-Protective Medications
 Aspirin .
 Clopidogrel .
 Newer antiplatelets agents ( Ticagrelor ) .
 Dual antiplatelet therapy-Aspirin+Clopidog)

Cardio-Protective Medications
 B-blockers .
 ACE inhibitors .
 Angiotensin receptor blockers .
 Statins .
Influenza vaccination
 Annual influenza vaccination as a preventive

measure for CV diseases .
Anti-Anginal Medications
 B-blockers .
 Nitrates .
 Calcium channel blockers .
 Ranolazine .
Cautions
 Beta-blocker not prescribed with verapamil
>> risk of complete heart block .
 Verapamil & diltiazem avoided with BB &

with pt. has CHF .
 Diltiazem use e caution risk of bradycardia .

PCI indications
 Pts. With refractory symptoms while on
optimal medical therapy .
 Unable to tolerate optimal medical therapy

due to side effects .
PCI indications
 High risk features on non-invasive exercise

& imaging test .
CABG indications
 Remain symptomatic with optimal medical

therapy .
 Left main disease .

CABG indications
 Multi-vessels disease + proximal lt anterior
descending artery involvement .
 Reduced systolic function .
 DM .
Prinzmetal’s angina treatment
 Dihydropyridine calcium channel blocker

e.g Felodipine because of vasodilator
properties .
Acute coronary syndrome
 ST-elevation MI .
 Non ST-elevation acute coronary syndromes

includes :
 Non ST-elevation MI .
 Unstable angina .
Pathophysiology
 Most common characterized by plaque
rupture ( 75 % of cases ) & plaque erosion
( 25 % of cases ) .
 STEMI caused by complete occlusion of

epicardial coronary artery by thrombus at
site of plaque disruption .
Anteroseptal MI
 ECG changes : V1 – V4 .
 Coronary artery : Left anterior descending .

Inferior MI
 ECG changes : II , III , aVF .
 Coronary artery : Right coronary .

High lateral MI
 ECG changes : I , aVL .
 Coronary artery : First diagonal of LAD .

Lateral MI
 ECG changes : I , Avl + / - V5 – V6 .
 Coronary artery : Left Circumflex .

Posterior MI
 ECG changes : Tall R in V1-V2 with ST

depres in V1-V4 .
 Coronary artery : Usually left circumflex also

right coronary .
Venous drainage of the heart
 Coronary sinus drains into the right atrium .

Arterial supply of the heart
 Right aortic sinus >> RCA .

 Left aortic sinus >> LCA .
 RCA >> Posterior descending .
 RCA >> Supplies SA node & AV node .
 LCA >> LAD + Circumflex .
STEMI
 Ischemic chest pain .
 > 1 mm ST segment elevation in 2 or >

consecutive leads .
 New left BBB on ECG .
 ST segment depress in 2 or > precord leads

NSTE. ACS
 Ischemic chest pain .
 Absence of ST-segment elevation .
 Presence of ST-segment depression .
 T-wave inversion in ECG .

NSTE. ACS
 Abnormal cardiac biomarkers in NSTEMI .
 Normal cardiac biomarkers in UA .

Diagnosis
 ECG , the most specific finding for a

diagnosis of MI is >> Evolution of Q waves
on ECG .
 Cardiac enzymes .
Cardiac Enzymes
 Troponin T at 3 & 6 hours is adequate to

determine myocardial damage has occurred.
 Myoglobin is the first to rise 1 hr of MI .

Cardiac Enzymes
 CK-MB useful to look for re-infarction .
 GPBB ( Glycogen phosphorylase isoenzyme )

is an appropriate marker for early cardiac
muscle injury .
Elevated Troponin Causes
 Trauma .
 Cardioversion .
 Rhabdomyolysis .
 Pulmonary embolism .
 Pulmonary hypertension .
 Hypotension .
 HOCM .
Elevated Troponin Causes
 Myocarditis .
 Sepsis .
 Burns .
 Subarachnoid hage & Stroke .
 Infiltrative& autoimmune disorders
( sarcoidosis , amyloidosis , scleroderma ) .

 Drugs : Adriamycin , Herceptin .
Management
 Aspirin .
 Clopidogrel .
 LMWH .
 Oxygen do not routinely administer .

Management
 PCI is the gold standard treatment for STEMI
 Thrombolysis should be performed in pts.

Without access to primary PCI .
Management
 An ECG should be performed 90 minutes

following thrombolysis to assess whether
there has been > 50 % resolution in the ST
elevation .
Management
 If there has not been adequate resolution
then rescue PCI is superior to repeat
thrombolysis .
 For pts. Successfully treated with

thrombolysis , PCI has been shown to be
beneficial , the optimal timing of this is still
under investigations .
Thrombolysis
 Thrombolytic drugs activate plasminogen to
form plasmin >> degrades fibrin & help
breaks up thrombi .
 Primarily used in pts. With STEMI with ECG

criteria for thrombolysis within 24 hours of
typical pain .
Thrombolysis Others Indication
 Acute ischemic stroke .
 Acute pulmonary embolism with unstable

haemodynamic .
Thrmbolytic Drugs
 Streptokinase .
 Alteplase .
 Tenecteplase .
Thrombolysis ECG Criteria
 ST elevation > 1 mm in standard limb leads
 ST elevation > 2 mm in anterior chest leads
 New left bundle branch block

Thrombolysis Contraindications
 Active internal bleeding .
 GIT bleeding within the past month.
 Coagulation & bleeding disorders .
 Major trauma , major surgery or head injury
within 3 weeks .
 Recent significant head injury .
 CNS neoplasm .
Thrombolysis Contraindications
 Previuos Hagic stroke at any time .
 Ischemic stroke < 3 months .
 Prolonged CPR > half an hour .
 Known or suspected Aortic dissection .
 Pregnancy .
 Severe uncontrolled hypertension .
 Proliferative diabetic retinopathy .
 Allergy & oral anticoagulants .
Thrombolysis Side effects
 Hage .
 Hypotension more common with

streptokinase .
 Allergic reaction may occur with

streptokinase .
PCI
 Technique used to restore myocardial

perfusion in pts. With IHD both in pts. With
stable angina & acute coronary syndrome .
 Stents are implanted in around 95 % of pts.

Stent Types
 Bare-metal stent .
 Drug-eluting stents , stent coated with

paclitaxel or rapamycin which inhibit local
tissue growth < restenosis rates >
thrombosis rates .
Stent Types
 Following insertion the most important

factor in preventing stent thrombosis is
antiplatelet therapy , aspirin should be
continued indefinitely , the length of
clopidogrel depends on the type of stent ,
reason for insertion & consultant preference
Stent Complications
 Stent thrombosis due to platelet
aggregation most commonly in the first
month usually presents with acute MI .
 In-stent Restenosis due to excessive tissue

proliferation around stent most commonly
in the first 3-6 months .
Cholesterol embolisation syndr.
 Eosinophilia .
 Purpura .
 Livedo reticularis .
 Renal failure .
 Acute abdomen due to bowel ischaemia .
 Absent leg pulse .
6 Month Mortality Risk
 Nice guidelines of NSTEMI/UA are based on
6 month mortality risk :
 If > 1.5 % >> Clopidogrel for 12 months .
 If > 3 % >> IV GP IIb/IIIa receptor

antagonist + Coronary angiography within
96 hours .
Secondary Prevention
 ACE inhibitor .
 Beta-blocker .
 Aspirin .
 Statin .
Secondary Prevention
 Clopidogrel .
 Aldosterone antagonists , Aldactone .
 Lifestyle modifications include increasing

physical activity to 20 – 30 minutes per day.
Complications
 Cardiac arrest .
 Cardiogenic shock .
 Chronic Heart failure .
 Tachy arrhythmias .
Complications
 Brady arrhythmias .
 Pericarditis .
 Cardiac tamponade .
 Dressler’s syndrome .
Complications
 Left ventricular aneurysm .
 Left ventricular free wall rupture .
 Ventricular septal rupture .
 Acute MR .
Mechanism Of Action
 Clopidogrel : ADP receptor antagonist (

inhibits ADP binding to its platelet
receptor ) .
 Aspirin : A2 thromboxane inhibition .

Mechanism Of Action
 Enoxaparin : Activates antithrombin III

which in turn potentiates the inhibition of
coagulation factors xa .
Side Effect
 Statin : Rhabdomyolysis .
 Streptokinase : Bleeding .
Post MI Drugs Of Choice
 ACEI + BB + ASA + PLAVIX + STATINS + or

– ALDACTONE .
Unfractionated Heparin Uses
 Angiography within 24 hours .
 If creatinine > 265 Mmol/L .

MI Post Recent Operation
 MI occur in post recent operation 3 days

associated with risk of bleeding , the most
appropriate treatment is primary
percutaneous coronary intervention .
Pericarditis
 Most specific ECG marker for pericarditis is

PR depression .
Conclusion
 Gold standard treatment for ST elevation MI
>> Primary percutaneous coronary
intervention ( PCI ) .
 DVLA advise post MI can not drive for 4

weeks .
Conclusion
 Importance of 12 months of dual anti-

platelet therapy ( Aspirin + Clopidogrel )
after placement of drug eluting stent .
Conclusion
 Complete heart block following inferior MI
not indicated for pacing ( temporary
pacemaker ) & managed conservatively .
 Complete heart block following anterior MI

indicated for pacing (temporary pacemaker)
Conclusion
 IV GTN used to control elevated BP in acute
coronary syndrome .
 Unfractionated heparin used if there is renal

impairment as elevated creatinine .
Conclusion
 The most common cause of death in pts.

Following a myocardial infaraction is
ventricular fibrillation .
Conclusion
 The single most important risk factor for

stent thrombosis after PCI is premature
withdrawal of antiplatelet therapy .
Thank you

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CoronaryPneumonia

 Stable Angina Pectoris is the most common

 Symptoms occur when atheromatous plaque

 Precipitated by physical exertion .

 Relieved by rest or GTN in about 5 minutes

 Pts. With 2 features have atypical angina .

 Pts. With 1 or none feature have non-

 For pts. With an estimated risk of 10 – 90 %

 Exercise testing is no longer recommended.

 Resting ECG abnormalities like ST segment

 WPWS & those w. ventricular pacing rhythm.

 Estimated likelihood of CAD 61 – 90 % .

 Persistent or progressive symptoms while

 High risk criteria on non invasive stress test

 Dobutamine stress echo .

 Contrast enhanced MR perfusion .

 MR imag. for stress induce wall motion abn.

 Estimated likelihood of CAD is 10 – 29 % .

 Pts. Who are unable to exercise because of :

 Aortic stenosis & Aortic regurgitation .

 Percutaneous coronary intervention .

 Daily physical activity .

 Newer antiplatelets agents ( Ticagrelor ) .

 Dual antiplatelet therapy-Aspirin+Clopidog)

 Angiotensin receptor blockers .

 Annual influenza vaccination as a preventive

 Calcium channel blockers .

 Verapamil & diltiazem avoided with BB &

 Diltiazem use e caution risk of bradycardia .

 Unable to tolerate optimal medical therapy

 High risk features on non-invasive exercise

 Remain symptomatic with optimal medical

 Left main disease .

 Reduced systolic function .

 Dihydropyridine calcium channel blocker

 Non ST-elevation acute coronary syndromes

 STEMI caused by complete occlusion of

 Coronary artery : Left anterior descending .

 ECG changes : II , III , aVF .

 Coronary artery : Right coronary .

 ECG changes : I , aVL .

 Coronary artery : First diagonal of LAD .

 ECG changes : I , Avl + / - V5 – V6 .

 Coronary artery : Left Circumflex .

 ECG changes : Tall R in V1-V2 with ST

 Coronary artery : Usually left circumflex also

 Coronary sinus drains into the right atrium .

 Right aortic sinus >> RCA .

 > 1 mm ST segment elevation in 2 or >

 New left BBB on ECG .

 ST segment depress in 2 or > precord leads

 Absence of ST-segment elevation .

 Presence of ST-segment depression .

 T-wave inversion in ECG .

 Abnormal cardiac biomarkers in NSTEMI .

 Normal cardiac biomarkers in UA .

 ECG , the most specific finding for a

 Troponin T at 3 & 6 hours is adequate to

 Myoglobin is the first to rise 1 hr of MI .