1. Coronary Artery Disease
Andrew C Rankin
Glasgow Royal Infirmary

2. Coronary Artery Disease
Angina
Myocardial
Infarction
Asymptomatic
Unstable
angina

3. Atherosclerosis Timeline
Complicated
Lesion/
Rupture
Foam
Cells
Fatty
Streak
Intermediate
Lesion
Atheroma
Fibrous
Plaque
Endothelial Dysfunction
From First
Decade
From Third
Decade
From Fourth
Decade
Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).

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

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

6. Coronary Angiography
Left coronary artery

7. Coronary Angiography
Right coronary artery

8. Death rates from CHD, (per 100,000) men and women aged 35-74, 1994, selected countries
Latvia
Russian Federation
Lithuania
Hungary
Czech Republic
Ireland
Romania
Finland UK
Poland
Norway
Denmark
Sweden
USA
Austria
Germany
Australia
Canada
Netherlands
Luxembourg
Greece
Italy
Mexico
men
Portugal
women
Spain
France
Japan
1000
800
600
400
200
200
400

9. P Q R S
T wave

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

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

13. Drug Therapy for Angina
Beta-blockers Calcium Nitrates K+ Channel
Antagonists Activator
Acebutolol
Atenolol
Bisoprolol
Carvedilol
Labetolol
Metoprolol
Nadolol
Oxprenolol
Pindolol
Propranolol
Timolol
I Verapamil
II Amlodipine
Felodipine
Nicardipine
Nifedipine
Nisoldipine
II Diltiazem
GTN
Isosorbide
Dinitrate
Mononitrate
Nicorandil

14. PCI / PTCA = Angioplasty

15. Coronary stents

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

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

18. ST depression

19. ST elevation

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

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 doesn’t work!
e.g. Fibrinolytic Therapy Trialist (1994)
3563 patients with suspected AMI
ST segment depression
Mortality 15.2% vs 13.8%

26. ECG and outcome in ACS
ST ¯
P  0.001
ST ­
T-wave inversion
GUSTO IIb

27. Troponin level and mortality in ACS
Mortality at 42 Days
831
174
148
134 50 67  %

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
Presentation
Working
Diagnosis
Chest pain
Acute coronary syndrome
No ST elevation
ST elevation
ECG
Troponin
Final
diagnosis
Myocardial Infarction
STEMI
NSTEMI +
Unstable Angina -