Your Heart

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• Your Heart
• Would you get Standard Rates?
• Dr Jeremy Sayer
• Consultant Cardiologist
• St. Bartholomews Hospital

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Summary

• Cardiovascular Risk
• Estimation of cardiovascular risk
• Further risk assessment
• ECG, Exercise ECG, EBCT, MSCT
• The Future
• Hypercholesterolaemia
• Valvular Disorders
• The natural history
• Cardiomopathy
• HCM, LVH or Athletes Heart?

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Heart disease in UK
Men
Women
Causes of deaths, 2003, United Kingdom
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Pathology
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Coronary artery plaque and its consequences
Vessel wall
Atheroma
Lumen
Left ventricular cavity
Area of infarction
Clot
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Risk factors for Coronary Artery Disease
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Risk factors for Coronary Artery Disease Markers
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Risk factors for Coronary Artery Disease Those
difficult to measure
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Risk factors for Coronary Artery
Disease Standard measures
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Estimated 10 year risk () of coronary artery
disease in a 55 year oldData from the Framingham
Study. Am J Hypertens 1994775
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Calculation of CHD Risk
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Case 1 a typical 55 year old male

• 55 year old
• Smoker
• Blood pressure 160 mmHg
• Cholesterol 7.5mmol/l
• Family history

The persons depicted in this presentation are
entirely fictitious. Any resemblance to people
living or dead is purely coincidental
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Case 1 a typical 55 year old male

• 55 year old
• Smoker
• Blood pressure 160 mmHg
• Cholesterol 7.5mmol/l
• (Family history)

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Case 2 a healthy 40 year old male

• 40 year old
• Non smoker
• Blood pressure 120 mmHg
• Cholesterol 4.2mmol/l
• No family history

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Case 2 a healthy 40 year old male

• 40 year old
• Non smoker
• Blood pressure 120 mmHg
• Cholesterol 4.2mmol/l
• No family history

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Case 3 single risk factor

• 40 year old
• Non smoker
• Blood pressure 120 mmHg
• Cholesterol 7.5mmol/l
• No family history

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Case 3 single risk factor

• 40 year old
• Non smoker
• Blood pressure 120 mmHg
• Cholesterol 7.5mmol/l
• No family history

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Case 4 mildly raised risk factors

• 40 year old
• Smoker
• Blood pressure 145 mmHg
• Cholesterol 5.4mmol/l
• No family history

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Case 4 mildly raised risk factors

• 40 year old
• Smoker
• Blood pressure 145 mmHg
• Cholesterol 5.4mmol/l
• No family history

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Further Risk Stratification
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Further Risk AssessmentThe Resting ECG
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Further Risk AssessmentSensitivity and
Specificity
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Normal ECG
Normal in 50 on patients with chronic stable
angina
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Further Risk AssessmentThe Exercise ECG
Sensitivity 50 - 60 Specificity 70
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Outcome of 25,927 asymptomatic men undergoing ETT
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Further Risk AssessmentMyocardial Perfusion
Scanning
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Further Risk AssessmentMyocardial Perfusion
Scanning
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http//www.hearthealthywomen.org/professionals/tes
ting__diagnosis/stress_test__ecg_6.html
Comparison of Noninvasive Exercise Tests
Meta-analyses
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Further Risk AssessmentCoronary Angiography
Forssmann 1929 Right heart catheter
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Further Risk AssessmentCoronary Angiography
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Intravascular Ultrasound (IVUS)
IVUS image of inside a coronary artery.ICIVUS
catheter, Llumen, Pplaque
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Intravascular Ultrasound (IVUS)
Nissen SE et al. JAMA 2004 291(9)1071-1080
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Further Risk AssessmentElectron Beam CT and
Calcium Scoring
Calcification of the left anterior descending
coronary artery (large arrow) and left circumflex
coronary artery (small arrow)
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Adapted from Am J Cardiac Imaging 199610180-6
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Further Risk AssessmentMulti-slice CT
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Further Risk AssessmentCardiac MR
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The Activated Endothelium
Adapted from Koenig W. Eur Heart J 19991(Suppl
T)T19-26.
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Markers of Inflammation in the Prediction of
Cardiovascular Disease in Women
Relative Risk
Relative Risk
hs-CRP
SAA
Total Cholesterol
Total Cholesterol
Relative Risk
Relative Risk
sICAM-1
IL-6
Total Cholesterol
Total Cholesterol
hs-CRP, high-sensitivity C-reactive protein SAA,
serum amyloid A sICAM, serum intracellular
adhesion molecule IL, interleukin. Ridker PM,
et al. N Engl J Med. 2000342836-843. (with
permission)
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Hypercholesterolaemia and IHD
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Endogenous Pathway of Lipid
Metabolism
LPL Lipoprotein lipase
HL Hepatic lipase
LPL
LDL
LDL
IDL
IDL
IDL
HL
LPL
LDL
LDL
receptor
receptor
HL
Small
Small
VLDL
LPL
VLDL
HL
Large
Large
VLDL
VLDL
Liver
Liver
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Reverse Cholesterol Transport
Cell
membrane
Liver
SRB1
LDL
receptor
CE
CE
FC
VLDL, IDL, LDL
LCAT
CETP
HDL
HDL3
TG
Peripheral
tissues
Free cholesterol
FC
TG
Triglycerides
CE
Cholesterol esters
LCAT
Lecithin cholesterol acyl transferase
CETP
Cholesteryl ester transfer protein
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Classification of DyslipidaemiasFredrickson
(WHO) Classification
Phenotype I IIa IIb III IV V
Lipoprotein elevated Chylomicrons LDL LDL and
VLDL IDL VLDL VLDL and chylomicrons
Atherogenicity None seen
Prevalence Rare Common Common Intermediate C
ommon Rare
Serum cholesterol
Serum triglyceride
Normal to
Normal
Normal to
Normal to
LDL low-density lipoprotein IDL
intermediate-density lipoprotein VLDL very
low-density lipoprotein. (High-density
lipoprotein (HDL) cholesterol levels are not
consideredin the Fredrickson classification.)
(Adapted from Yeshurun et al., 1995)
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(a) Achilles tendon xanthoma (b) tendon
xanthomata on the dorsum of a hand (heterozygous
familial hypercholesterolaemia) and (c) planar
xanthoma in the antecubital fossa (homozygous
familial hypercholesterolaemia). Courtesy of
Professor PN Durrington.
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..and the rest...
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Valve Disease
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Mitral Regurgitation
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Aortic valve Disease
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Mild and moderate aortic stenosis
Natural history and risk stratification by
echocardiography
European Heart Journal (2004) 25, 199205
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Aortic Regurgitation
BONOW ET AL., ACC/AHA TASK FORCE REPORTJACC Vol.
32, No. 5, November 19981486-1588
                                                  
                                                  
           
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Left Ventricular Hypertrophy, Hypertrophic
Cardiomyopathy and Athletes Heart
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Left Ventricular Dimensions and Athletes Heart
Relative impact of different types of sports
training on left ventricular (LV) cavity
dimension and wall thickness (expressed as a
percentage of maximum)
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Left Ventricular Dimensions and Athletes Heart
Distribution of LV dimensions in trained athletes
N Engl J Med 1991 324295301
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Ventricular ectopics
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THANK YOU
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ADDITIONAL SLIDES
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DEFINITION OF MYOCARDIAL INFARCTION
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Definition of Myocardial Infarction

• World Health Organisation (WHO) definition
• Two out of three of
• Typical symptoms
• Typical enzyme rise
• Typical ECG (with the development of Q waves)

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Definitions of Myocardial Infarction
Pathological diagnosis - loss of cardiac myocytes
(necrosis) by prolonged ischaemia WHO 2 out of 3
of Typical symptoms Enzyme rise Typical ECG
pattern
European Heart Journal (2000) 21,
15021513 doi10.1053/euhj.2000.2305, available
online at http//www.idealibrary.com
on Consensus Document
Myocardial infarction redefined A consensus
document of The Joint European Society of
Cardiology/American College of Cardiology
Committee for the Redefinition of Myocardial
Infarction The Joint European Society of
Cardiology/American College of Cardiology Committe
e
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SUMMARY Definition of MI Criteria for acute,
evolving or recent MI Either one of the following
criteria satisfies the diagnosis for an acute,
evolving or recent MI (1) Typical rise and
gradual fall (troponin) or more rapid rise and
fall (CK-MB) of biochemical markers of myocardial
necrosis with at least one of the following (a)
ischemic symptoms (b) development of Q
waves (c) ECG changes indicative of ischemia
(ST segment elevation or depression) (d)
coronary artery intervention (e.g.,
coronary angioplasty). (2) Pathologic findings of
an acute MI. Criteria for established MI Any one
of the following criteria satisfies the diagnosis
for established MI (1) Development of new
pathologic Q waves on serial ECGs. The patient
may or may not remember previous symptoms.
Biochemical markers of myo-cardialnecrosis may
have normalized, depending on the length of time
that has passed since the infarct developed. (2)
Pathologic findings of a healed or healing MI.
Troponin levels Myocardial necrosis is detected
if Maximal concentration of troponin T or I
exceeds the decision limit (99th percentile of
the values for a reference control group) on at
least one occasion during the first 24 h after
the index clinical event

• Implications
• Identification of more infarcts (but this would
  seem reasonable since any rise in Troponin is
  associated with adverse outcome)
• Allows appropriate secondary prevention in more
  cases
• Excludes previously mislabelled infarcts
• Social implications - HGV licenses, pilots
  licenses, life insurance, psychological

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Cardiac Troponins
TnT
TnC
TnI

• 100 specific for myocardial damage
• Released within first few hours
• Peak at 12-24hours
• TnT detectable up to 14 days
• TnI detectable up to 5-7 days
• Allow quantification of infarct size
• Prognostic indicators
• Guide therapy
• Sensitivity Specificity
• CK 90 90
• AST 90 65
• TnT 100 100

Actin
Tropomyosin
Components of Cardiac Muscle
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CHD - Troponins
Risk Stratification in Unstable Angina Role of
Troponin T
0.62-2.12
gt2.12
0.18-0.62
0.06-0.18
lt0.06
Cumulative risk of cardiac death or MI based on
Tropnin T levels (?g/l)
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CHD - Troponins
Risk Stratification in Unstable Angina Role of
Troponin T and ECG Changes
Lindahl. Circulation 1996931651
gt0.18?g/l
TnT
0.06-0.18?g/l
lt0.06?g/l
Five-months risk of cardiac death or MI in
relation to resting ECG and tropnin T levels
during the first 24h in the FRISC trial
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CHD - Troponins
Risk Stratification in Unstable Angina Role of
Troponin T and Exercise Testing
Lindahl. Eur Heart J 199718762
High risk ETT
Intermediate risk ETT
High risk
Low risk ETT
Five-months risk of cardiac death or MI in
relation to exercise test response and tropnin T
levels during the first 24h in the FRISC trial
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CHD - definition
Acute Coronary Syndrome
ST Elevation
No ST Elevation
Unstable Angina
Myocardial Infarction
NonQWMI
NSTEMI
QWMI