1. ISCHAEMIC HEART DISEASE Acute Coronary Syndromes JD Marx Department of Cardiology University of the Free State

2. Acute Coronary Syndromes PATHOPHYSIOLOGY  Intermittent, partial or total occlusion of coronary artery responsible for acute myocardial ischaemia  Several factors play a role

3. Acute Coronary Syndromes PATHOPHYSIOLOGY Unstable angina MI Ischemic stroke/TIA Critical leg ischemia Intermittent claudication CV death Atherosclerosis Stable angina intermittent claudication Thrombosis MI=myocardial infarction ACS=acute coronary syndromes TIA=transient ischemic attack CV=cardiovascular ACS

4. Acute Coronary Syndromes  Vulnerable plaque present in most patients  Culprit lesions most often a low grade lesion 1. Atherosclerotic Lesions in ACS

5. Acute Coronary Syndromes Multiple Unstable Lesions

6. Acute Coronary Syndromes T LYMPHOCYTES 7% 25% 29% 6% 29% 43% RECURRENT UAP 2. Inflammation in ACS

7. Acute Coronary Syndromes  Thrombosis on ulcerated or ruptured plaque plays pivotal role › Platelet Thrombus › Fibrin Thrombus 3. Thrombus in ACS

8. Platelet Adhesion Tissue factor, vWF COLLAGEN I GP lb- IX GP IIb - IIIa GP Ia - IIa Plaque rupture, endothelial damage, fibrous cap erosion

9. Platelet Activation and Aggregation Platelet Thrombin ADP Thromboxane A 2 Epinephrine Serotonin Collagen PAR-1 PAR-4 P2Y 1 P2Y 12 TXA2-R 5HT 2 A Anionic phospholipid surfaces GP IIb GP IIIa GP VI Platelet GP IIIa GP IIb Fibrinogen GP Ia

10. Platelet Aggregation Flowing disc- shaped platelet Rolling ball-shaped platelet Hemisphere- shaped platelet Spreading platelet FIRM, BUT REVERSIBLE ADHESION IRREVERSIBLE ADHESION Scanning electron micrograph of discoid, dormant platelets Activated, aggregating platelets illustrating fibrin strands

11. Platelet Thrombus

12. Thrombus on Plaque Rupture

13. 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.

14. Acute Coronary Syndromes  Thrombosis on ulcerated or ruptured plaque plays pivotal role › Platelet Thrombus › Fibrin Thrombus 3. Thrombus in ACS

16. Fibrin Thrombus

17. Can play an important etiological role Acute Coronary Syndromes 4. Coronary Artery Spasm in ACS

19. Acute Coronary Syndromes PATIENT 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

20. Acute Coronary Syndromes Unstable Angina Pectoris & Non ST-segment elevation infarction TREATMENT 1.Medical Stabilization a)General i.Hospitalization ii.Monitor as appropriate iii.Pain relief iv.Sedation as necessary Identify and treat precipitating factors e.g. anaemia, tachiarrhythmias

21. Acute Coronary Syndromes TREATMENT b)Drugs i.Antithrombotic Antiplatelet e.g.. Aspirin Anticoagulant e.g.. Heparin ii.Antianginal Nitrates β-Blockers Calcium Antagonists iii.Disease Modifying Drug Statins ACE Inhibitors

22. Acute Coronary Syndromes TREATMENT 2.Coronary Angiography Evaluate coronary anatomy Depending on clinical and anatomic findings an appropriate long term treatment is determined.

23. Acute Coronary Syndromes LONG TERM TREATMENT  Medical therapy  Coronary angioplasty  Coronary artery Bypass Graft surgery

24. Diffuse Disease MAHOMED

25. Right Coronary Artery Before PTCA After PTCA

26. Stenting LAD BEFORE STENT LAD AFTER STENT

27. Multi vessel disease: Surgery

28. Patent LIMA

29. Patent SVG

30. Thank you