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Ischemic Heart Disease Group of diseases Most common cause of death in developed countries Terminology: 1.Angina pectoris 2.Myocardial infarction 3.Sudden cardiac death 4.Chronic ischemic heart disease –Coronary artery disease –Acute coronary disease
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Ischemic Heart Disease Common in older adults: –>60 in males –>70 in females –M>F Fisk factors: hypertension, Diabetes, smoking, high cholesterol, genetic factors Factors reducing the risk: regular exercise, alcohol.
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Ischemic Heart Disease Pathogenesis: –Atherosclerosis of coronary arteries –Stenosis (narrowing) of the lumen Mild, moderate, sever “critical” >75% stenosis –Changes in atheromatous plaques: 1.Acute plaque change: –fissuring, hemorrhage, rupture with embolism –Usually occurs in moderate stenosis –How does it occur? –Metalloproteinase from macrophages, T-cell activation, hemodynamic trauma
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Ischemic Heart Disease Pathogenesis: –Changes in atheromatous plaques: 2. Coronary artery thrombosis –Complete occlusion resulting in infarction –Incomplete occlusion resulting in unstable angina –Embolization 3. Coronary artery vasospasm –Other pathology: Emboli from aorta or valves vasculitis Severe hypotension Left ventricular hypertrophy
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Angina Pectoris Intermittent chest pain caused by transient reversible myocardial ischemia 1.Typical “stable” angina Episodic chest pain Crushing sub-sternal Radiate to left arm Due to fixed atherosclerotic narrowing Usually with critical stenosis >75% Relieved by rest or nitroglycerin
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Angina Pectoris Intermittent chest pain caused by transient reversible myocardial ischemia 2. Prinzmetal (variant) angina: Occurs at rest, awaken the patient from sleep Due to coronary artery spasm 3. Unstable angina: Increase in frequency of angina With less and less exercise Last longer Due to acute changes in atheromatous plaque or thrombosis
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Myocardial Infarction Myocardial necrosis caused by local ischemia In the US 1.5 million cases with 500,000 deaths per year Age group 45-54 year, M:F 4:1
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Myocardial Infarction Pathogenesis: –Coronary artery thrombosis –Necrosis of cardiac muscle after 20-30 minutes of complete occlusion –Necrosis begins in the subendothelial zone –Depends on the vessel involved: Left anterior descending (40-50%): anterior and apical area of the LV with anterior 2/3 rd of septum Right coronary artery (30-40%): posterior and basal area of the LV, posterior 1/3 rd of the septum Circumflex artery: lateral wall of the LV
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Myocardial Infarction Morphology: –12 h: no change –12-18 h: coagulative necrosis –18-24 h: neutrophils –3 days: peak of inflammation –If reperfusion occurs it results in hemorrhage –4-7 days: well-defined pale region, with macrophages, and fibroblasts –10 days: granulation tissue –4 weeks: collagen depsition –8 weeks: scar
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Myocardial Infarction Complications: –Left ventricular failure (60%) –Cardiogenic shock (10%) –Papillary muscle dysfunction/infarction/rupture –Rupture of LV (4-8%) –Mural thrombi (15%) –Ventricular aneurysm –Acute pericarditis
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Myocardial Infarction Clinical: –Sever, crushing sub-sternal chest pain –Radiate to neck, jaw, shoulder and left arm –Last for hours –Dyspnea due to pulmonary edema –If large(>40%) leads to cardiogenic shock –“silent” MI in diabetics and elderly –ECG changes –Elevated CK, troponin, LDH –25% death due to arrhythmia
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Chronic Ischemic Heart Disease Development of progressive congestive heart failure as a consequence of long-term ischemia Usually with Moderate-severe coronary artery stenosis Pervious MI and scarring Dilated heart
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Sudden Cardiac Death Excluding: homicide, suicide, trauma and toxins Causes: heart disease, pulmonary embolism, rupture aortic aneurysm, CNS Ischemic heart disease is the most common cause Death due to ventricular arrhthmia
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