Coronary Artery Coronary Artery DiseaseDisease
Andrew C RankinAndrew C Rankin
Glasgow Royal InfirmaryGlasgow Royal Infirmary
AsymptomaticAsymptomatic Myocardial Myocardial InfarctionInfarction
AnginaAngina
UnstableUnstableanginaangina
Coronary Artery DiseaseCoronary Artery Disease
Atherosclerosis TimelineAtherosclerosis TimelineFoamFoamCells Cells
FattyFattyStreak Streak
IntermediateIntermediateLesion Lesion AtheromaAtheroma
FibrousFibrousPlaquePlaque
ComplicatedComplicatedLesion/Lesion/RuptureRupture
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).
From FirstDecade
From ThirdDecade
From FourthDecade
Endothelial DysfunctionEndothelial Dysfunction
Risk Factors for Atherosclerotic Disease
Hoeg JM. JAMA. 1997;277:1387–1390.
Non-modifiable
AgeFamily historySex
Modifiable
Cigarette smokingDiabetes mellitusHyperlipidemiaHypertensionObesityPhysical inactivity
Right Coronary Artery
Posterior Descending Artery
Left Main Coronary Artery
Diagonal Artery
Left Anterior Descending Artery
Coronary arteriesCoronary arteries
Coronary AngiographyCoronary Angiography
Left coronary arteryLeft coronary artery
Coronary AngiographyCoronary Angiography
Right coronary arteryRight coronary artery
JapanFrance
SpainPortugal
MexicoItaly
GreeceLuxembourg
NetherlandsCanada
AustraliaGermany
AustriaUSA
Sweden
DenmarkNorway
PolandUK
FinlandRomania
IrelandCzech Republic
HungaryLithuania
Russian FederationLatvia
0200400600800 200 4001000
Death rates from CHD, (per 100,000) men and women aged 35-74, 1994, selected countries
men
women
PP
RR
SS
T waveT wave
Mechanisms of Action of Mechanisms of Action of Anti-Anginal DrugsAnti-Anginal Drugs
Improve Blood SupplyImprove Blood Supply• Coronary VasodilatationCoronary Vasodilatation
Reduce Cardiac WorkloadReduce Cardiac Workload• Slow Heart RateSlow Heart Rate• Reduce Force of ContractionReduce Force of Contraction• Reduce Pre-load / After-loadReduce Pre-load / After-load
AntianginalsAntianginals Adalat LAAdalat LAAdipine MRAdipine MRAdizem-XLAdizem-XLAngiopine MRAngiopine MRAngitil SRAngitil SRBeta-AdalatBeta-AdalatBeta-PrograneBeta-PrograneBetalocBetalocBetimBetimBlocadrenBlocadrenBritiazimBritiazimCardeneCardeneCardilate MRCardilate MRCedocardCedocard
CoractenCoractenCordiloxCordiloxCorgardCorgardCoro-NitroCoro-NitroDeponitDeponitDilzem SRDilzem SRElantan Elantan LALAEmcorEmcor
GlytrinGlytrinIkorelIkorelImdurImdurInderal LAInderal LAIsib 60XLIsib 60XLIsmoIsmo
IsoketIsoketIsordilIsordilIstinIstinLopresorLopresorMCR-50MCR-50MinitranMinitranMonitMonitMono-CedocardMono-CedocardMonocorMonocorMonomaxMonomaxMyocardolMyocardolNitro-DurNitro-DurNitrocineNitrocineNitrolingualNitrolingual
NitronalNitronalPercutolPercutol
Probeta LAProbeta LASectralSectralSecuron SRSecuron SRSlow-TrasicorSlow-TrasicorSlozemSlozemSorbichewSorbichewSorbidSASorbidSASorbitrateSorbitrateSuscardSuscardSustacSustac
TenifTenifTenorminTenormin
Tildiem LATildiem LATotamolTotamolTrandateTrandateTransidermTransidermTrasicorTrasicorUniverUniver
ViskenVisken
EucardicEucardic
IsocardIsocard NitrominNitromin
PlendilPlendilPosicorPosicor
Syscor MRSyscor MR
Viazem XLViazem XL
Tensipine MRTensipine MR
Drug Therapy for AnginaDrug Therapy for Angina
Drug Therapy for AnginaDrug Therapy for AnginaBeta-blockersBeta-blockers CalciumCalcium NitratesNitrates KK++ Channel Channel
AntagonistsAntagonists ActivatorActivatorAcebutolol Acebutolol AtenololAtenololBisoprololBisoprololCarvedilolCarvedilolLabetololLabetololMetoprololMetoprololNadololNadololOxprenololOxprenololPindololPindololPropranololPropranololTimololTimolol
II VerapamilVerapamil
IIII AmlodipineAmlodipineFelodipineFelodipineNicardipineNicardipineNifedipineNifedipineNisoldipineNisoldipine
IIII DiltiazemDiltiazem
GTNGTN
IsosorbideIsosorbideDinitrateDinitrate
IsosorbideIsosorbideMononitrateMononitrate
NicorandilNicorandil
PCI / PTCA = AngioplastyPCI / PTCA = Angioplasty
Coronary stentsCoronary stents
Acute Coronary Acute Coronary SyndromesSyndromes
Acute Myocardial InfarctionAcute Myocardial Infarction Unstable anginaUnstable angina
• Rest painRest pain• Crescendo anginaCrescendo angina• New onset anginaNew onset angina
Role of Platelets in Thrombus Formation
in Acute Ischemic Events
MIMI
StrokeStroke
Vascular Vascular DeathDeath
ThromboticThromboticOcclusionOcclusion
AtheroscleroticAtheroscleroticVesselVessel
LipidCore
PlaquePlaqueRuptureRupture
Platelet Adhesion,Platelet Adhesion,Activation, and Activation, and
AggregationAggregation
ThrombusThrombusFormationFormation
ST depressionST depression
ST elevationST elevation
0 6 12 18 24 2 3 4 5 6 7 8 9 10
RE
LA
TIV
E C
ON
CE
NT
RA
TIO
N
DaysHours
TIME AFTER INFARCT
Normal
TroponinMyoglobin
CK, ASTLDH
Complications of Acute MI
Acute MIAcute MIExpansion / AneurysmExpansion / Aneurysm RV InfarctRV Infarct
PericarditisPericarditis
MechanicalMechanical Mural ThrombusMural Thrombus
ArrhythmiaArrhythmia
Heart FailureHeart Failure
Extension / IschemiaExtension / Ischemia
LVRV
ISIS-2.Lancet 1988;11:349–360
Acute coronary syndromeAcute coronary syndrome
No ST elevationNo ST elevationST elevationST elevation
Thrombolytic therapyThrombolytic therapyPCIPCI
??
Thrombolysis for ACS Thrombolysis for ACS without ST elevation?without ST elevation?
It doesn’t work!It doesn’t work!e.g. Fibrinolytic Therapy Trialist (1994)e.g. Fibrinolytic Therapy Trialist (1994)
• 3563 patients with suspected AMI• ST segment depression• Mortality 15.2% vs 13.8%
GUSTO IIbGUSTO IIb
0%
2%
4%
6%
8%
10%
0 30 60 90 120 150 180
Days from Randomization
Mo
rtal
ity
T-wave inversion
ST-segment depression
ST-segment elevation
0%
2%
4%
6%
8%
10%
0 30 60 90 120 150 180
Days from Randomization
Mo
rtal
ity
T-wave inversion
ST-segment depression
ST-segment elevation
T-wave inversionT-wave inversion
ST ST
ST ST
P 0.001P 0.001
ECG and outcome in ACSECG and outcome in ACS
1.01.7
3.4 3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/ml)
1.01.7
3.4 3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/ml)
Mo
rtal
ity
at 4
2 D
ays
Mo
rtal
ity
at 4
2 D
ays
831831 174174 148148 134134 5050 6767
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Troponin level and mortality in ACSTroponin level and mortality in ACS
Myocardial infarction redefinedMyocardial infarction redefinedWHO definition: (2 of 3)WHO definition: (2 of 3)
• Typical symptoms (chest pain)
• Typical ECG changes (Q waves)
• Enzyme riseESC/ACC redefinition 2000ESC/ACC redefinition 2000• Troponin rise, with one of:• Chest pain• ECG changes (Q waves or ST segment)• PCI
Acute coronary syndromeAcute coronary syndrome
No ST elevationNo ST elevationST elevationST elevation
Chest painChest painPresentationPresentation
WorkingWorkingDiagnosisDiagnosis
Myocardial InfarctionMyocardial Infarction
STEMISTEMI NSTEMINSTEMI
++
++
Unstable AnginaUnstable Angina
--
ECGECG
TroponinTroponin
Final Final diagnosidiagnosiss