Coronary Heart Disease
Coronary Heart Disease
Coronary Heart Disease
Disease
M Chadi Alraies 1
The main reason to invest in
prevention is to promote health
and extend life, improve
functioning and prevent
suffering.
M Chadi Alraies 2
General considerations
number one killer in
the United States
and worldwide.
Every minute, an
American dies of
coronary heart
disease.
Coronary heart
disease afflicts over
13 million
Americans. M Chadi Alraies 3
The estimated cost for cardiovascular
disease in 1994 by the American
Heart Association is 128 billion
dollars.
M Chadi Alraies 4
An 82-year-old woman presents for her annual
examination. She has hypertension and is on
chronic β-blocker therapy. She denies all cardiac
symptoms. She takes a daily 1-mile walk, and her
exercise tolerance has not changed during the
past year.
Physical examination shows a blood pressure of
138/86 mm Hg, a regular pulse of 80/min, and a
respiratory rate of 16/min. Her jugular venous
pressure is 10 cm H2O, her carotid upstrokes are
normal, and her lungs are clear. Cardiac
examination reveals a normal S1, a single S2, and
a grade 3/6 early systolic murmur at the upper
left sternal border that radiates to her carotids.
Abdominal examination is benign, and there is 1+
peripheral edema. Laboratory data are
remarkable for a total cholesterol of 210 mg/dL
(5.43 mmol/L), with an LDL cholesterol of 110
mg/dL (2.84 mmol/L).
Her echocardiogram from 2 years ago showed
moderate calcific aortic
M Chadistenosis,
Alraies with a 5
Which is the most appropriate next
step?
A Reassurance
B Begin a cardiac rehabilitation program
C Begin hydrochlorothiazide
D Start statin therapy
M Chadi Alraies 6
Risk factors
Abnormal lipids
Smoking
Hypertension
Diabetes mellitus
Abdominal obesity
Psychosocial factors
Consumption of too few
fruits and vegetables.
Too much alcohol
Lack of regular physical
activity.
M Chadi Alraies 7
What is the
number one
preventable cause
of cardiovascular
disease worldwide?
SMOKING!
M Chadi Alraies 8
1 year after
quitting, the risk of
coronary heart
disease decreases
by 50%
M Chadi Alraies 9
Framingham
score
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Women Men
M Chadi Alraies 12
Define the
metabolic
syndrome?
M Chadi Alraies 13
The metabolic syndrome
Three or more of the following:
Abdominal obesity
Triglycerides 150 mg/dL
Hypertension.
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Obesity
BMI = or > 30 kg/m2
33% of the adult population in the
2003–2004 survey.
Low-fat diets appear to be at least as
effective as other diets for weight
loss
M Chadi Alraies 15
A 72-year-old woman is seen for a routine office
evaluation to establish care. Past medical history
includes only hypertension, hyperlipidemia, and a
familial history of coronary artery disease. She
does not smoke. She is active and walks daily and
denies angina, dyspnea, fatigue, and edema.
Physical examination reveals a blood pressure of
128/70 mm Hg. There are no carotid bruits. There
is a normal S1 and a physiologically split S2.
There is a grade 2/6 midsystolic murmur that
does not radiate and is best heard at the 2nd
right intercostal space. The rest of the physical
examination is unrevealing.
Which of the following diagnostic tests is most
appropriate at this time?
A No further testing at this time
B Transthoracic echocardiography
C Electron-beam CT M Chadi Alraies 16
Pathophysiology
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Lipid metabolism in relation
to formation of
atherosclerotic lesions
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Formation of a fatty streak in
an artery
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Formation of atheroma
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Plaque rupture
Many atherosclerotic plaques remain
stable or progress only gradually.
Rupture, often related to the
inflammatory process.
The rupture causes…
Turbulent flow
Extrusion of lipids and fatty gruel
M Chadi Alraies 21
Plaque rupture
All result in a cascade of events
culminating in intravascular thrombosis.
The outcome of these events is…
Complete vessel occlusion.
Partial vessel occlusion (causing the symptoms
of unstable angina or myocardial infarction)
Restabilization often with more severe
stenosis.
Transient occlusion and/or embolization of
platelet and thrombin debris, which may
result in elevation in serum troponin,
predispose to clinical events and portend a
worse prognosis. M Chadi Alraies 22
Plaque rupture
M Chadi Alraies 23
Screening and Diagnosis
me me show s
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Si t
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Narrow i
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A 22-year-old women who is 16 weeks pregnant
is evaluated for a 2-hour history of severe
anterior chest pain radiating to her mid back. She
is a tall, thin woman with a pectus abnormality of
her chest and long, thin fingers. Her blood
pressure is 140/80 mm Hg, her pulse is 94/min
and regular, and her respiratory rate is 24/min.
Her chest wall is diffusely mildly tender to
palpation. Her lungs are clear to auscultation.
Cardiac auscultation shows a normal S1, a
physiologically split S2, and a grade 2/6 diastolic
decrescendo murmur at the left sternal border.
There is no peripheral edema. Her
electrocardiogram shows only nonspecific ST-T
changes. Oxygen saturation by pulse oximetry on
room air is 99%. Her D-dimer level is mildly
elevated.
Which is the most likely cause of her chest pain?
A Pulmonary embolusM Chadi Alraies 25
Primary &
Secondary
Prevention of
Coronary Heart
Disease
M Chadi Alraies 26
AHA/ACC
Secondary
Prevention for
Patients With
Coronary and
Other Vascular
Disease
2006 Update
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M Chadi Alraies 28
Coronary and Other
Vascular Disease
Established coronary disease.
Atherosclerotic vascular disease:
Peripheral arterial disease,
Atherosclerotic aortic disease, and
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SMOKING
Goal: Complete cessation. No exposure to
environmental tobacco smoke.
Ask about tobacco use status at every
visit.
Advise every tobacco user to quit.
Assess the tobacco user’s willingness to
quit.
Assist by counseling and developing a plan
for quitting.
Arrange follow-up, referral to special
programs, or pharmacotherapy (including
nicotine replacement and bupropion).
Urge avoidance ofM Chadi
exposure
Alraies
to 30
A 55-year-old man is evaluated for cough, scant
clear-to-yellow sputum, and malaise of 3 days'
duration. He has not had fever, chills, wheezing,
or pleuritic chest pain, or recent contact with
anyone who has been ill. He has a 40-pack-year
smoking history and has had similar symptoms
three times in the past 6 months, feeling well in
the intervals between episodes.
On physical examination, temperature is 37.2 °C
(99.0 °F), and pulse rate, respiration rate, and
blood pressure are normal. The cardiopulmonary
examination is normal, including clear lungs on
auscultation with no signs of consolidation.
Which of the following is the most appropriate
initial smoking-cessation management step
during this visit?
M Chadi Alraies 33
A 55-year-old man is evaluated for epigastric
discomfort that has been increasing in frequency
despite the use of antacids. The discomfort
occurs with exercise, but at times he is able to
exercise without provocation of his symptoms. He
has no other medical conditions and takes only
an 81-mg aspirin daily and occasional chondroitin
sulfate for joint aches.
Physical examination, including vital signs and
cardiac examination, is normal.
Electrocardiogram shows normal sinus rhythm
with normal waveforms. Lipid tests show total
cholesterol of 199 mg/dL (5.15 mmol/L), LDL
cholesterol of 131 mg/dL (3.39 mmol/L), and HDL
cholesterol of 35 mg/dL (0.91 mmol/L).
What is the most appropriate next step in the
evaluation of this patient?
A Measurement of C-reactive protein
B Measurement of coronary calcium by electron-beam
CT M Chadi Alraies 34
LIPID
MANAGEMENT
M Chadi Alraies 35
LDL
“The lower the better”
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HDL
“The higher the better”
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LIPID MANAGEMENT
1. Start dietary therapy.
2. Reduce intake of saturated fats (to <7%
of total calories),
3. Cholesterol (to <200 mg/d).
4. LDL-C <100 mg/dL
5. non-HDL-C should be <130 mg/dL
6. Adding plant stanol/sterols (2 g/d) and
viscous fiber (>10 g/d) will further lower
LDL-C.
7. Encourage increased consumption of
omega-3 fatty acids in the form of fish or
in capsule form (1 g/d) for risk reduction.
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LIPID MANAGEMENT
Assess fasting lipid profile in all
patients, and within 24 hours of
hospitalization for those with an
acute cardiovascular or coronary
event.
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LIPID MANAGEMENT
For hospitalized patients, initiate lipid-lowering
medication as recommended below before
discharge according to the following schedule:
LDL-C should be <100 mg/dL and…
Further reduction of LDL-C to <70 mg/dL is reasonable.
If baseline LDL-C is 100 mg/dL, initiate LDL-lowering
drug therapy.
If on-treatment LDL-C is 100 mg/dL, intensify LDL-
lowering drug therapy (may require LDL-lowering drug
combination.
If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to
treat to LDL-C <70 mg/dL.
If triglycerides are 200 to 499 mg/dL, non-HDL-C should
be <130 mg/dL. And…
Further reduction of non-HDL-C to <100 mg/dL is
reasonable. M Chadi Alraies 40
LIPID MANAGEMENT
Therapeutic options to reduce non-
HDL:
More intense LDL-C–lowering therapy
Niacin or
Fibrate therapy
M Chadi Alraies 43
HDL
Has been shown to be Cardioprotective
in the Framingham Heart Study, and in
retrospective analyses of intervention
trials such as the Coronary Primary
Prevention Trial and the Multiple Risk
Factor Intervention Trial 5-7
M Chadi Alraies 45
A 32-year-old woman is brought to the hospital with chest
pain at rest after a party. She has had similar pain
previously, primarily in the morning and rarely with
exertion. The pain usually subsides spontaneously and
occasionally is associated with diaphoresis but rarely
dyspnea. She almost lost consciousness at work during the
most recent episode. She smokes a half pack of cigarettes
a week and has occasionally inhaled cocaine. She is
otherwise healthy and takes no medications. She has no
family history of coronary artery disease.
Her blood pressure is 128/70 mm Hg and pulse rate is
72/min. There is no neck vein distention or carotid bruits.
The lungs are clear and cardiac examination reveals a
normal S1 and S2 and a faint mid-systolic click but no
murmur. Examination of the abdomen and extremities is
normal. Electrocardiogram shows a 1-mV inferior ST-
segment elevation; a subsequent electrocardiogram is
normal. Serum troponin concentration is 1.5 times the
upper limit of normal. Therapy with heparin, aspirin,
metoprolol, and nitroglycerin is begun. The next morning,
coronary angiography shows normal angiographic
appearance of the arteries and normal left ventricular wall
motion. The patient is prescribed a daily aspirin and
encouraged to stop using cocaine.
M Chadi Alraies 48
WEIGHT MANAGEMENT
Maintain/achieve…
A BMI (18.5 - 24.9)
Waist circumference: men <40 inches,
women <35 inches.
The initial goal of weight loss therapy
should be to reduce body weight by
approximately 10% from baseline.
With success, further weight loss can
be attempted if indicated through
further assessment.
M Chadi Alraies 49
DIABETES MANAGEMENT
Goal: HbA1c <7%
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ANTIPLATELET AGENTS/
ANTICOAGULANTS
Start aspirin 75 to 162 mg/d unless
contraindicated.
For patients undergoing CABG,
aspirin should be started within 48
hours after surgery.
Doses higher than 162 mg/d can be
continued for up to 1 year.
M Chadi Alraies 51
ANTIPLATELET AGENTS/
ANTICOAGULANTS
Start and continue clopidogrel 75
mg/d in combination with aspirin for
up to 12 months in patients after:
ACS, PCI with stent placement
Patients who have undergone
percutaneous coronary intervention
with stent placement should initially
receive higher-dose aspirin at 325
mg/d for 1 month for bare metal.
M Chadi Alraies 52
ANTIPLATELET AGENTS/
ANTICOAGULANTS
Manage warfarin to international
normalized ratio=2.0 to 3.0 for
paroxysmal or chronic atrial
fibrillation or flutter
Use of warfarin in conjunction with
aspirin and/or clopidogrel is
associated with increased risk of
bleeding and should be monitored
closely.
M Chadi Alraies 53
A 68-year-old man recently diagnosed with adenocarcinoma
of the cecum undergoes preoperative evaluation before
surgical resection. His medical history includes inoperable
coronary artery disease, heart failure with a left ventricular
ejection fraction (LVEF) of 35%, hypertension, and
hyperlipidemia. Angina is stable, occurring approximately
monthly, and he has no orthopnea or paroxysmal nocturnal
dyspnea. Medications include lisinopril, carvedilol,
furosemide, simvastatin, and daily aspirin. He plays golf
weekly, using a cart, walks 2 miles three to four times
weekly, and carries groceries up a flight of stairs to his
apartment.
On physical examination, the pulse rate is 64/min, and
blood pressure is 120/64 mm Hg. Jugular venous pressure is
6 cm. On cardiopulmonary examination, the lungs are clear
to auscultation, and the heart is regular without an S3.
There is no peripheral edema. Laboratory studies, including
complete blood count, serum electrolyte levels, and renal
function, are normal. The electrocardiogram is unchanged,
with a normal sinus rhythm and evidence of an old inferior
infarction.
Which of the following is the most appropriate next step in
the preoperative evaluation of this patient?
A Plasma B-type natriuretic peptide measurement
B Echocardiography
C Exercise stress testingM Chadi Alraies 54
RENIN-ANGIOTENSIN-
ALDOSTERONE SYSTEM
BLOCKERS
M Chadi Alraies 55
ACE inhibitors
Start and continue indefinitely in all
patients with…
LV EF 40%.
HTN,
DM
M Chadi Alraies 56
Angiotensin receptor
blockers
Intolerance of ACE inhibitors
Heart failure
Myocardial infarction with left
ventricular ejection fraction 40%.
Consider use in combination with
ACE inhibitors in systolic-dysfunction
heart failure.
M Chadi Alraies 57
A 55-year-old man with coronary artery disease
is evaluated 2 weeks after having had a
myocardial infarction. On discharge, his
medications included aspirin, sustained-release
metoprolol, isosorbide mononitrate, lisinopril,
and atorvastatin. Echocardiogram at that time
showed inferior and posterior wall akinesis and a
left ventricular ejection fraction of 40%. On
examination, his heart rate is 60/min and his
blood pressure is 130/70 mm Hg. Jugular venous
pressure is normal and the chest is clear. Cardiac
rhythm is regular, with normal S1 and S2 and no
murmurs or extra heart sounds. Laboratory
results from yesterday are potassium 5.7 meq/L
(5.7 mmol/L), creatinine 1.0 mg/dL (88.42
µmol/L), and LDL cholesterol 65 mg/dL (1.68
mmol/L). Lisinopril therapy is stopped.
Wich of the following medications should be
started in this patient?
3. Valsartan
4. Spironolactone M Chadi Alraies 58
Aldosterone blockade
Use in post–myocardial infarction
patients, without…
Significant renal dysfunction or
Hyperkalemia
M Chadi Alraies 59
ß-BLOCKERS
Myocardial infarction,
Acute coronary syndrome,
LV dysfunction
Vascular disease
Diabetes
M Chadi Alraies 60
INFLUENZA VACCINATION
Patients with cardiovascular disease
should have an influenza vaccination.
M Chadi Alraies 61
Antioxidant
(HOPE) trial found that vitamin E may
even be harmful by increasing the
likelihood of heart failure and other
trials have suggested that vitamin E
may hinder the effectiveness of
statin therapy.
M Chadi Alraies 62
Elevated plasma
homocysteine levels
Associated with an increased risk of
vascular events.
Reduced with dietary supplements of
folic acid (1 mg/d) in combination
with vitamin B6 and vitamin B12.
RCT showed they are of little or no
value in preventing vascular events.
M Chadi Alraies 63
Hormone replacement
therapy HRT
In HERS trial, neither combined
estrogen–progesterone nor estrogen
alone therapy is protective (in fact
both cause harm).
M Chadi Alraies 64
Fish oil
Fish, rich in omega-3 fatty acids, may
help protect against vascular
disease, and it is recommended that
it be eaten three times a week by
patients at risk.
M Chadi Alraies 65
A 35-year-old man is evaluated during a routine
examination. He does not smoke and has no
family history of early coronary artery disease.
On examination, BMI is 35.2, and waist
circumference is 114 cm (45 in). Blood pressure is
142/88 mm Hg. The remainder of the physical
examination is normal. Laboratory studies
indicate borderline hyperglycemia (fasting plasma
glucose, 121 mg/dL [6.7 mmol/L]). Serum total
cholesterol level is 246 mg/dL (6.36 mmol/L),
high-density lipoprotein level is 31 mg/dL (0.8
mmol/L), and low-density lipoprotein level is 158
mg/dL (4.05 mmol/L).
Which of the following recommendations is most
appropriate for this patient?
A Electron-beam CT
B Exercise treadmill test
C Hydrochlorothiazide
D Intensive lifestyle modification
M Chadi Alraies 66
Pathophysiology of Chronic
Ischemia & Acute Coronary
Syndromes
Chronic ischemia, including stable
angina, is classically caused by
supply and demand mismatch.
Precipitants include exercise, eating,
cold weather, and emotional stress.
M Chadi Alraies 67
Pathophysiology of Chronic
Ischemia & Acute Coronary
Syndromes
ACS of unstable angina and MI
caused by:
Plaque disruption
Platelet and thrombin-mediated
coronary thrombosis
Coronary spasm
Microvascular dysfunction.
M Chadi Alraies 69
Types & Pathophysiology of
myocardial ischemia
presentation
Symptomatic, causing angina
pectoris.
Completely silent.
In patients with diagnosed CAD
silent ischemic episodes have the
same prognostic import as
symptomatic ones.
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Myocardial Hibernation &
Stunning
Areas of myocardium that are persistently
underperfused.
Still viable
May develop sustained contractile
dysfunction.
May lead to LV failure.
Reversible following coronary
revascularization.
Identified by
Radionuclide testing, (PET), MRI,
Inotropic stimulation with dobutamine.
M Chadi Alraies 71
Myocardial Hibernation &
Stunning
A related phenomenon, termed
"myocardial stunning," is the
occurrence of persistent contractile
dysfunction following prolonged or
repetitive episodes of myocardial
ischemia.
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