s table coronary artery disease yeditepe university faculty of medicine phase 4 cardiology course...
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STABLE CORONARY ARTERY DİSEASE
YEDITEPE UNIVERSITY FACULTY OF MEDICINE
PHASE 4 CARDIOLOGY COURSE 2014-2015
PROF. MUZAFFER DEGERTEKIN, M.D., PhD.
MUSTAFA AYTEK SIMSEK, M.D., Attending Physician
ATHEROSCLEROTIC ATHEROSCLEROTIC CARDIOVASCULAR CARDIOVASCULAR
DIASEASEDIASEASE
Stable Ischemic Heart Disease
Acute Coronary Syndrome
ST-Segment Elevation Myocardial Infarction
Unstable Angina and Non–ST Elevation Myocardial Infarction
DEFİNİTİONDEFİNİTİON
Coronary artery diseaseCoronary artery disease::
used to describe coronary arteries affected by a pathological process.
the narrowing of the coronary arteries or blockage of coronary blood flow, usually caused by atherosclerosis.
This can cause chest pain, shortness of breath, or myocardial infarction.
NONATHEROSCLEROTİC CADNONATHEROSCLEROTİC CAD Coronary artery spasm Arteritis/vasculitis Occlusion of a coronary artery due to dissecting
aneurysm Coronary embolism Syphilitic aortitis involving the coronary ostia Cocaine induced vasospasm Vasospasm and/or thrombosis due to
hypersensitivity (Kounis syndrome) Congenital abnormalities
DEFİNİTİONDEFİNİTİON
Ischemic heart dIschemic heart disease isease ((Coronary Coronary heart diseaseheart disease or atherosclerotic or atherosclerotic heart disease)heart disease)
Cardiac disease resulting from myocardial ischemia.
Although myocardial ischemia also occurs in such conditions as aortic stenosis or anemia, the term ‘ischemic heart disease’ is generally applied only to cases of atherosclerotic origin.
DEFİNİTİONDEFİNİTİON ArteriosclerosisArteriosclerosis – a general term describing
any thickening and hardening of artery walls and loss of elasticity of medium or large arteries.
AtherosclerosisAtherosclerosis – process where fatty material is deposited along walls of arteries. This material thickens, hardens, and can eventually block the artery.
Atherosclerosis is just one type of arteriosclerosis
2013 SCAD GUIDELINE
MAGNITUDE OF THE PROBLEM
The leading cause of death The lifetime risk of developing symptomatic CAD after
age 40 (Framingham Heart Study) 49% for men 32% for women
ANGINAAngina is a type of chest discomfort
caused by poor blood flow through the coronary vessels to myocardium (≥70% reduction in luminal diameter of a major coronary artery).
ANGINA: EXERTIONALANGINA: EXERTIONALCoronary artery obstructions are not sufficient to
result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results.
Angina:Variant AnginaAngina:Variant Angina
• Transient impairment of coronary blood supply by vasospasm or platelet aggregation
• Majority of patients have an atherosclerotic plaque
• Generalized arterial hypersensitivity• Long term prognosis very good
ANGINA: SILENT ISCHEMIAANGINA: SILENT ISCHEMIA Very common More episodes of silent than painful ischemia in
the same patient No pain, but ischemic ECG changes Most common in diabetics (due to neuropathy)
Difficult to diagnose Holter monitor Exercise testing As significant as chronic SAP in terms of the subsequent
risk of ACS events, as well as mortality and morbidity.
Symptoms other than angina:Breathlessness
Feeling of faintness
Anxiety
Flatulence or other dispeptic complaints
ANGINA: ANGINAL EQUIVALENT ANGINA: ANGINAL EQUIVALENT SYNDROMESYNDROME
Patient’s with exertional dyspnea rather than exertional chest pain
Caused by exercise induced left ventricular dysfunction
Shortness of breath, diaphoresis
EVALUATE ANGİNA PECTORİS
1. Location
2. Characteristics
3. Precipitating factors
4. Duration
5. Relieved
LOCATİON Usually substernal, May extend to
the left or right chest, the shoulders, the neck, jaw, arms (usually ulnar surface of
left arm), epigastrium and the upper
back) Occasionally,the radiated
pain may be more noticeable to the patient than the origin of the pain
CHARACTERİSTİCS
Deep, visceral and intense Many patients describe it as a
pressure–like, squeezing sensation
Rather than sharp or stabbing or pinprick-like pain
PRECİPİTATİNG FACTORS
Exercise, heavy meal, cold weather the emotional stress Other events that obviously
increase myocardial oxygen demand, such as rapid tacharrhytmias,
extreme elevations in blood pressure,
decrease in oxygen supply such as anemia.
DURATİON
Angina pectoris is transient lasting between 2 and 30 minutes.
Typically 2-10 minutes
The duration of the pain is minutes, not seconds, not hours
Chest pain that lasts longer than 30 min is more consistent with myocardial infarction, pain of less than 2 min is unlikely to be due to myocardial ischemia
RELİEVED BY
cessation of the precipitating event such as exercise, or
the administration of treatment such as sublingual nitroglycerine.
Angina – Types:
Typical Angina:
Atypical Angina:
Noncardiac chest pain
Stable Angina: reproducible, predictable
Unstable Angina: new onset, increased freq, intensity, duration, or occurs at rest
PRE TEST PROBABILITY OF CORONARY DISEASE BY SYMPTOMS, GENDER AND AGE
CCSC ANGINA CLASSIFICATIONCCSC ANGINA CLASSIFICATION
PHYSİCAL EXAMİNATİONPHYSİCAL EXAMİNATİON May be completely normal
S3 or S4 may be heard
Mitral regurgitation
Blood pressure
Body mass index
Waist circumference
ELECTROCARDİOGRAM ELECTROCARDİOGRAM (ECG)(ECG) All patients with suspected angina should
have a resting ECG.
May be completely normal (especially between attacks of angina)
Evidence of old myocardial infarction, bundle branch block, left ventricular hypertrophy
Electrocardiogram Electrocardiogram (ECG)(ECG)• Ischemia at rest: “non-specific T and ST
changes”• changes in the T-wave or the ST segment that are “out of place”
• normally, the T-wave and the QRS complex have similar polarity
• T-wave flattening:
• T-wave inversion:
• ST-segment scooping:
•ST-segment depression:
I
III
II
AVR
AVL
AVF
Inferior Ischemia in a 42 year old male at rest
Anteriolateral ischemia in a 67 year old female while at rest
V1
V3
V2
V4
V6
V5
LABORATORY LABORATORY EXAMİNATİONEXAMİNATİON Hemoglobin Creatinine Glucose Lipids Thyroid function High sensitive CRP Homocysteine NTproBNP Troponins
CHEST X-RAYCHEST X-RAY Patients with suspected heart failure
Patients with clinical evidence of significant pulmonary disease
ECHOCARDIOGRAPHYECHOCARDIOGRAPHYUsed to assess...
Myocardial Structures
– MR, TR, AR Ventricular Function
– EF
– Wall motion abnormalities Effusions
Thrombus
Ischemia
SCREENING AND DIAGNOSISSCREENING AND DIAGNOSIS
StressStressTestTest
measures
measures
bloo
dbl
ood
supplysupply
to h
eart
to h
eart
CoronaryCoronaryAngiographyAngiography
spec
ific
spec
ific
showsshows
coro
nar
ies
coro
nar
ies
Narrowing inNarrowing in
Sites of
Sites of
Electro-Electro-cardiogramcardiogram
measures
measures
elec
tric
alel
ectr
ical
impulses
impulses
EXERCISE STRESS TESTING EXERCISE STRESS TESTING
The most widely used
The least expensive CAD screening modality
Exercise stress Exercise stress testtest• Ischemia during exercise: ST-segment
depression• usually indicative of subendocardial ischemia
• location of ischemia does not always correspond to the leads in which it is seen
J-point.08 seconds
Quantity or depth of ST-segment depression
Baseline
Treadmille
Continued until The patient becomes fatigued Achieves 85% of the maximum predicted heart rate (approximately 220 minus the patient's age)
Terminated Signs or symptoms of severe ischemia (angina, ST-segment elevation, ST-segment depression >0.3 mV, or a fall in blood pressure of 10 mm Hg), arrhythmias, or heart block develop
Treadmille
Computer summaries can help find possible areas of ischemia – then review raw data carefully!
Determine PQ junction, J point, ST80, and estimate slope
Elevation Depression
Upsloping Horizontal Downsloping
ST SEGMENT INTERPRETATION
Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with a relatively stable baseline are selected. The PQ junction (1) and J point (2) are determined; the ST 80 (3) is determined at 80 msec after the J point. In this example, average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The average slope measurement from
the J point to ST 80 is –1.1 mV/sec.
Normal
Rapid Upsloping
Minor ST Depression
Slow Upsloping
Horizontal
Downsloping
Elevation (non Q lead)
Elevation (Q wave lead)
Duke treadmill score = duration of exercise in minutes on the Bruce protocol- (minus) 5x maximal mm ST deviation- (minus) 4x treadmill angina index
Treadmill Angina Index:0 if no angina.1 if non-limiting angina.2 if limiting angina.
High Risk = treadmill score < -1079% 4-year survivalModerate Risk = treadmill score -10 to +495% 4-year survivalLow Risk = treadmill score >+599% 4-year survival
Duke Nomogram for 2 mm depression, non-limiting chest
pain at 5 METS.
STRESS ELECTROCARDIOGRAPHIC STRESS ELECTROCARDIOGRAPHIC INDICATORS OF SEVERE CORONARY INDICATORS OF SEVERE CORONARY DISEASE OR POOR PROGNOSIS DISEASE OR POOR PROGNOSIS
Downsloping ST-segment depression ≥3 mV Involvement of five or more leads with ST-
segment depression Early ST-segment depression (<5 METS) Prolonged ST-segment depression late into
recovery Failure to complete stage II of Bruce protocol Failure to obtain HR >120/min (off negative
chronotropic drugs) Exertional hypotension
MYOCARDIAL PERFUSION MYOCARDIAL PERFUSION IMAGING (THALLIUM SCAN)IMAGING (THALLIUM SCAN)
Used to assess... Ischemia (diagnosis and prognosis of CAD)
Ventricular Function
– Ejection Fraction Myocardial Viability
– Reversible vs non-reversible
Diagnosis/prognosis for CADDiagnosis/prognosis for CAD when when Non-diagnostic EST Abnormal resting ECG Negative EST with continued chest pain Intermediate probability of disease
Defined CADDefined CAD• Post infarct risk stratification• Risk stratification to determine need
for revascularization ( viability study )
STRESS STRESS ECHOECHOCARDİOGRAPHYCARDİOGRAPHY Ischemia may cause wall motion
abnormalities, no rise of fall in LVEF Sensitivity/specificity same as nuclear testing May be better in women
MANAGEMENTMANAGEMENT Lifestyle modificiations
Medical Treatment
Invasive Procedures
Prevention
LİFESTYLE MODİFİCİATİONSLİFESTYLE MODİFİCİATİONS Diet & salt restriction
Weight reduction
Smoking
Physical activity
Avoid precipitating factors (walking into a wind or uphill, cold weather, large meals)
MEDİCAL MEDİCAL TREATMENTTREATMENT
Aspirin
ACE inhibitors
Beta-blockers
Calcium channel blockers
Nitrates
Statins
TREATMENT ALGORITHMTREATMENT ALGORITHM
NITRATESNITRATES
Increase in intracellular cyclic guanosine monophosphate (cGMP) levels and cause smooth muscle relaxation
Venous vasodilation/pre-load reduction Arterial dilation/after-load reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Antiplatelet and antithrombotic effects
NITRATESNITRATES
Side EffectsHeadacheFlushingHypotension and syncope (take first dose
sitting)Palpitations Tolerance (to reduce tolerance, smaller doses
with less frequent dosing building in a nitrate-free interval of 8-12 hours and avoidance of long-acting formulations unless a prolonged nitrate-free interval is provided)
StatinsStatins Reduces the risk of atherosclerotic
cardiovascular complications in both primary and secondary prevention settings.
Block cholesterol synthesis in the liver by inhibiting the enzyme 3-hydroxy-3-methyl-glutaryl coenzyme A reductase.
Atorvastatin, rosuvastatin, simvastatin, pravastatin, fluvastatin...
Not only lower cholesterol levels but also antiinflammatory and antithrombotic effects (pleiotropic effects)
LİPİD LOWERİNG DRUGSLİPİD LOWERİNG DRUGS Fibrates
Reduce TG and to a lesser extent cholesterol and LDL. Nicotinic acid
Reduce TG and to a lesser extent cholesterol and LDL. increases HDL Side effects (flushing)
Bile acid sequestrants Anion exchange resins binds with cholesterol-containing bile acids in the intestine,
and promoting the conversion of cholesterol to bile acids in the liver.
BETA-BLOCKERSBETA-BLOCKERS
Metoprolol, bisoprolol, propranolol, atenolol Decrease myocardial oxygen consumption Blunt exercise response, block the action of
catecholamines in increasing heart rate, blood pressure, and cardiac contractility
Try to avoid drugs with intrinsic sympathomimetic activity
First line therapy in all patients with angina if possible
BETA BLOCKERS BETA BLOCKERS
Side EffectsBronchospasm Diminished exercise capacity and
fatigue Negative inotropy Sexual dysfunction Bradyarrhythmia Masking of hypoglycemia Increased claudication Hair loss
CALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERS
Verapamil, diltiazem, nifedipine, nicardipine, amlodipine, felodipine
Arterial dilation/afterload reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Improved subendocardial perfusion Slowing of heart rate with diltiazem, verapamil
CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS
Side Effects Palpitations Headache Ankle edema Gingival hyperplasia Constipation
INVASİVE TREATMENT INVASİVE TREATMENT PERCUTANEOUS CORONARY INTERVENTION (PCI)
Indications for Angioplasty (+/- stenting)
CORONARY ARTERY BYPASS GRAFT (CABG)
Indications Left main disease > 50 %
Proximal 3 vessel disease
Multivessel disease with left ventricular dysfunction
Better in diabetics
Lifestyle limiting angina unresponsive to medical therapy and/or PCI