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Coronary Artery Disease Andrew C Rankin Glasgow Royal Infirmary.

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Presentation on theme: "Coronary Artery Disease Andrew C Rankin Glasgow Royal Infirmary."— Presentation transcript:

1 Coronary Artery Disease Andrew C Rankin Glasgow Royal Infirmary

2 AsymptomaticMyocardialInfarction Angina Unstableangina Coronary Artery Disease

3 Atherosclerosis Timeline FoamCellsFattyStreakIntermediateLesionAtheromaFibrousPlaque ComplicatedLesion/Rupture Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104). From First Decade From Third Decade From Fourth Decade Endothelial Dysfunction

4 Risk Factors for Atherosclerotic Disease Hoeg JM. JAMA. 1997;277:1387–1390. Non-modifiable Age Family history Sex Modifiable Cigarette smoking Diabetes mellitus Hyperlipidemia Hypertension Obesity Physical inactivity

5 Right Coronary Artery Posterior Descending Artery Left Main Coronary Artery Diagonal Artery Left Anterior Descending Artery Coronary arteries

6 Coronary Angiography Left coronary artery

7 Coronary Angiography Right coronary artery

8 Japan France Spain Portugal Mexico Italy Greece Luxembourg Netherlands Canada Australia Germany Austria USA Sweden Denmark Norway Poland UK Finland Romania Ireland Czech Republic Hungary Lithuania Russian Federation Latvia Death rates from CHD, (per 100,000) men and women aged 35-74, 1994, selected countries men women

9 P QRS T wave


11 Mechanisms of Action of Anti-Anginal Drugs Improve Blood Supply Coronary Vasodilatation Coronary Vasodilatation Reduce Cardiac Workload Slow Heart Rate Slow Heart Rate Reduce Force of Contraction Reduce Force of Contraction Reduce Pre-load / After-load Reduce Pre-load / After-load

12 Antianginals Adalat LA Adipine MR Adizem-XL Angiopine MR Angitil SR Beta-Adalat Beta-Prograne Betaloc Betim Blocadren Britiazim Cardene Cardilate MR Cedocard Coracten Cordilox Corgard Coro-Nitro Deponit Dilzem SR Elantan LA Emcor Glytrin Ikorel Imdur Inderal LA Isib 60XL Ismo Isoket Isordil Istin Lopresor MCR-50 Minitran Monit Mono-Cedocard Monocor Monomax Myocardol Nitro-Dur Nitrocine Nitrolingual Nitronal Percutol Probeta LA Sectral Securon SR Slow-Trasicor Slozem Sorbichew SorbidSA Sorbitrate Suscard Sustac Tenif Tenormin Tildiem LA Totamol Trandate Transiderm Trasicor Univer Visken Eucardic Isocard Nitromin Plendil Posicor Syscor MR Viazem XL Tensipine MR Drug Therapy for Angina

13 Beta-blockersCalcium NitratesK + Channel AntagonistsActivator AcebutololAtenololBisoprololCarvedilolLabetololMetoprololNadololOxprenololPindololPropranololTimolol IVerapamil IIAmlodipine FelodipineNicardipineNifedipineNisoldipine IIDiltiazem GTNIsosorbideDinitrateIsosorbideMononitrate Nicorandil

14 PCI / PTCA = Angioplasty

15 Coronary stents

16 Acute Coronary Syndromes Acute Myocardial Infarction Acute Myocardial Infarction Unstable angina Unstable angina Rest pain Rest pain Crescendo angina Crescendo angina New onset angina New onset angina

17 Role of Platelets in Thrombus Formation in Acute Ischemic Events MI MI Stroke Stroke Vascular VascularDeath Thrombotic Occlusion Atherosclerotic Vessel Lipid Core Plaque Rupture Platelet Adhesion, Activation, and Aggregation Thrombus Formation

18 ST depression

19 ST elevation



22 Complications of Acute MI Acute MI Expansion / Aneurysm RV Infarct Pericarditis Mechanical Mural Thrombus Arrhythmia Heart Failure Extension / Ischemia LVRV

23 ISIS-2.Lancet 1988;11:349–360

24 Acute coronary syndrome No ST elevation ST elevation Thrombolytic therapy PCI ?

25 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%

26 GUSTO IIb T-wave inversion ST P ECG and outcome in ACS

27 Mortality at 42 Days % % % % % % % % % % % % Troponin level and mortality in ACS

28 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


30 Acute coronary syndrome No ST elevation ST elevation Chest pain PresentationWorkingDiagnosis Myocardial Infarction STEMI NSTEMI + + Unstable Angina - ECGTroponinFinaldiagnosis


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