ISCHAEMIC HEART DISEASE Acute Coronary Syndromes
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ISCHAEMIC HEART DISEASE Acute Coronary Syndromes
JD MarxDepartment of Cardiology
University of the Free State
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Acute Coronary SyndromesPATHOPHYSIOLOGY
Intermittent, partial or total occlusion of coronary artery responsible for acute myocardial ischaemia
Several factors play a role
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Acute Coronary SyndromesPATHOPHYSIOLOGY
Unstable angina MI Ischemic stroke/TIACritical leg ischemiaIntermittentclaudicationCV death
Atherosclerosis
Stable angina intermittent claudication
Thrombosis
MI=myocardial infarction ACS=acute coronary syndromes TIA=transient ischemic attack CV=cardiovascular
ACS
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Acute Coronary Syndromes
Vulnerable plaque present in most patients Culprit lesions most often a low grade lesion
1. Atherosclerotic Lesions in ACS
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Acute Coronary SyndromesMultiple Unstable Lesions
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Acute Coronary Syndromes
0%5%
10%15%20%25%30%35%40%45%
MACROPHAGES T LYMPHOCYTES
7%
25%29%
6%
29%
43%
RECU
RREN
T UA
P
2. Inflammation in ACS
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Acute Coronary Syndromes
Thrombosis on ulcerated or ruptured plaque plays pivotal role
› Platelet Thrombus
› Fibrin Thrombus
3. Thrombus in ACS
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Platelet Adhesion
Tissue factor, vWF
COLLAGEN I
GP lb- IX
GP IIb - IIIa
GP Ia - IIa
Plaque rupture, endothelial damage, fibrous cap erosion
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Platelet Activation and Aggregation
PlateletThrombin
ADP
Thromboxane A2
Epinephrine
Serotonin
Collagen
PAR-1
PAR-4P2Y1
P2Y12
TXA2-R
5HT2AAnionicphospholipidsurfaces
GP IIbGP IIIa
GP VI
Platelet
GP IIIaGP IIb
Fibrinogen
GP Ia
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Platelet Aggregation
Flowingdisc-
shapedplatelet
Rollingball-shaped
platelet
Hemisphere-shapedplatelet
Spreadingplatelet
FIRM, BUT REVERSIBLEADHESION
IRREVERSIBLEADHESION
Scanning electron micrograph of discoid, dormant platelets
Activated, aggregating platelets illustrating fibrin
strands
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Platelet Thrombus
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Thrombus on Plaque Rupture
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Microembolization in Unstable Angina
Courtesy of C. Michael Gibson, MS, MD, Director TIMI Data Coordinating Center, Brigham & Women’s Hospital, Associate Chief of Cardiology, Interventional Cardiologist, Beth Israel Deaconess Medical Center, Harvard Medical School.
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Acute Coronary Syndromes
Thrombosis on ulcerated or ruptured plaque plays pivotal role
› Platelet Thrombus
› Fibrin Thrombus
3. Thrombus in ACS
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Fibrin Thrombus
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Can play an important etiological role
Acute Coronary Syndromes4. Coronary Artery Spasm in ACS
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Acute Coronary SyndromesPATIENT WITH MYOCARDIUM AT RISK
CLINICAL PRESENTATION
Unstable Angina Pectoris› Angina of recent onset ( 1 month )› Angina at rest› Worsening angina› Early post infarction angina
Non ST-segment elevation myocardial infarction› Cardiac enzymes elevated e.g. troponins,CK, MB-CK
ST-segment elevation myocardial infarction› Normal progression to Q-wave infarction
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Acute Coronary SyndromesUnstable Angina Pectoris &
Non ST-segment elevation infarctionTREATMENT
1. Medical Stabilizationa) General
i. Hospitalizationii. Monitor as appropriateiii. Pain reliefiv. Sedation as necessary Identify and treat
precipitating factors e.g. anaemia, tachiarrhythmias
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Acute Coronary SyndromesTREATMENT
b) Drugsi. Antithrombotic • Antiplatelet e.g.. Aspirin• Anticoagulant e.g.. Heparin
ii. Antianginal• Nitrates• β-Blockers• Calcium Antagonists
iii. Disease Modifying Drug• Statins• ACE Inhibitors
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Acute Coronary SyndromesTREATMENT
2. Coronary AngiographyEvaluate coronary anatomy
Depending on clinical and anatomic findings an appropriate
long term treatment is determined.
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Acute Coronary SyndromesLONG TERM TREATMENT
Medical therapy
Coronary angioplasty
Coronary artery Bypass Graft surgery
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Diffuse Disease
MAHOMED
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Right Coronary Artery
Before PTCA After PTCA
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Stenting
LAD BEFORE STENT LAD AFTER STENT
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Multi vessel disease: Surgery
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Patent LIMA
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Patent SVG
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Thank you