Coronary Artery Disease

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Coronary Artery Disease
Andrew C Rankin Glasgow Royal Infirmary
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Coronary Artery Disease
Asymptomatic
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Atherosclerosis Timeline
Complicated Lesion/ Rupture
Foam Cells
Fatty Streak
Intermediate Lesion
Atheroma
Fibrous Plaque
From First Decade
From Third Decade
From Fourth Decade
Adapted from Pepine CJ. Am J Cardiol.
199882(suppl 104).
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Risk Factors for Atherosclerotic Disease

• Non-modifiable
• Age
• Family history
• Sex

• Modifiable
• Cigarette smoking
• Diabetes mellitus
• Hyperlipidemia
• Hypertension
• Obesity
• Physical inactivity

Hoeg JM. JAMA. 199727713871390.
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Coronary arteries
Left Main Coronary Artery
Right Coronary Artery
Diagonal Artery
Left Anterior Descending Artery
Posterior Descending Artery
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Coronary Angiography
Left coronary artery
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Coronary Angiography
Right coronary artery
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Death rates from CHD, (per 100,000) men and women
aged 35-74, 1994, selected countries
Latvia
Russian Federation
Lithuania
Hungary
Czech Republic
Ireland
Romania
Finland
UK
Poland
Norway
Denmark
Sweden
USA
Austria
Germany
Australia
Canada
Netherlands
Luxembourg
Greece
Italy
Mexico
men
Portugal
women
Spain
France
Japan
0
200
400
600
800
200
400
1000
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Mechanisms of Action of Anti-Anginal Drugs

• Reduce Cardiac Workload
• Slow Heart Rate
• Reduce Force of Contraction
• Reduce Pre-load / After-load

• Improve Blood Supply
• Coronary Vasodilatation

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Drug Therapy for Angina
Antianginals
Adalat LA
Coracten
Isocard
Nitromin
Syscor MR
Adipine MR
Cordilox
Nitronal
Isoket
Tenif
Percutol
Corgard
Isordil
Adizem-XL
Tenormin
Plendil
Coro-Nitro
Istin
Angiopine MR
Tensipine MR
Posicor
Deponit
Lopresor
Angitil SR
Tildiem LA
Probeta LA
Dilzem SR
MCR-50
Beta-Adalat
Totamol
Sectral
Elantan LA
Minitran
Beta-Prograne
Trandate
Securon SR
Emcor
Monit
Betaloc
Transiderm
Slow-Trasicor
Eucardic
Mono-Cedocard
Trasicor
Betim
Slozem
Glytrin
Monocor
Univer
Blocadren
Sorbichew
Ikorel
Monomax
Viazem XL
SorbidSA
Britiazim
Imdur
Myocardol
Visken
Sorbitrate
Cardene
Inderal LA
Nitro-Dur
Suscard
Cardilate MR
Isib 60XL
Nitrocine
Sustac
Ismo
Cedocard
Nitrolingual
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Drug Therapy for Angina
Beta-blockers Calcium Nitrates K
Channel Antagonists Activator
Acebutolol Atenolol Bisoprolol Carvedilol Labetol
ol Metoprolol Nadolol Oxprenolol Pindolol Proprano
lol Timolol
I Verapamil II Amlodipine Felodipine Nicardipin
e Nifedipine Nisoldipine II Diltiazem
GTN Isosorbide Dinitrate Isosorbide Mononitrate
Nicorandil
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PCI / PTCA Angioplasty
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Coronary stents
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Acute Coronary Syndromes

• Acute Myocardial Infarction
• Unstable angina

• Rest pain
• Crescendo angina
• New onset angina

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Role of Platelets in Thrombus Formation in Acute
Ischemic Events
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ST depression
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ST elevation
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Complications of Acute MI
LV
RV
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ISIS-2.Lancet 198811349360
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Acute coronary syndrome
No ST elevation
ST elevation
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Thrombolysis for ACS without ST elevation?

• It doesnt work!
• e.g. Fibrinolytic Therapy Trialist (1994)

• 3563 patients with suspected AMI
• ST segment depression
• Mortality 15.2 vs 13.8

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ECG and outcome in ACS
ST
P ? 0.001
ST
T-wave inversion
GUSTO IIb
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Troponin level and mortality in ACS
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Myocardial infarction redefined

• WHO definition (2 of 3)
• Typical symptoms (chest pain)
• Typical ECG changes (Q waves)
• Enzyme rise

• ESC/ACC redefinition 2000
• Troponin rise, with one of
• Chest pain
• ECG changes (Q waves or ST segment)
• PCI

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Chest pain
Presentation Working Diagnosis
Acute coronary syndrome
ECG Troponin Final diagnosis
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