Fcm - Coronary Artery Disease Angina Pectoris

Front 1

Angina pectoris

Back 1

Severe chest pain due to ischemia of the heart muscle. It is a consequence of myocardial oxygen demand exceeding myocardial oxygen supply.

Front 2

Myocardial ischemia

Back 2

A condition of myocardial oxygen deprivation due to inadequate perfusion.

Most often this is due to atherosclerotic obstruction in the large epicardial coronary arteries. Rupture of a preexisting atherosclerotic plaque may occur resulting in platelet-thrombus formation.

Occasionally, myocardial ischemia can occur despite a normal coronary circulation if an excessive myocardial oxygen demand outstrips the supply capability of coronary blood flow.

Front 3

Coronary artery disease

Back 3

End result of the accumulation of atheromatous plaques within the walls of the coronary arteries.

The number one cause of death in the industrialized world. In the US, it accounts for approximately 1 million deaths per year and is responsible for 1/3 of all deaths in persons between the ages of 35-65.

Front 4

Risk factors for CAD

Back 4

Advanced age, family history of CAD, hypertension, smoking, hyperlipidemia (especially high LDL cholestrol), low HDL cholesterol, and diabetes.

Obese patients are also at increased risk by virtue of their association with other risk factors.

An elevated level of the systemic inflammatory marker C-reactive protein, represents a powerful independent risk factor for CAD.

Front 5

Unstable angina

Back 5

Plaque rupture with subsequent intracoronary thrombosis and coronary vasospasm.

High risk of myocardial infarction and death.

Clinical subgroups - new onset angina, crescendo angina, rest angina, and post-infarction angina

Front 6

Cardiac catherization

Back 6

Cardiac catherization with selective angiography remains the gold standard method of diagnosing coronary artery disease. By the selective injection of radiographic contrast into the coronary arteries, it is possible to define the location and severity of obstructive lesions. In addition, left ventricular function can also be evaluated.

Provides information on the two most important prognostic determinants for patients with stable exertional angina: the state of left ventricular function and the anatomic extent of disease.

Front 7

Coronary artery bypass surgery

Back 7

Myocardial oxygen consumption is reduced to a minimum during the operation by placing the heart in an arrested state (asystole) and by slowing metabolism via hypothermia. Continued systemic circulation of oxygenated blodo is achieved via the cardiopulmonary bypass machine. The greater saphenous vein is removed from the leg and grafted from an incision in the ascending aorta to the coronary artery distal to the site of the coronary artery obstruction.

The internal mammary artery can also be dissected free from the chest wall and used for bypass grafting; this conduit is used routinely for bypassing the left anterior descending artery because of superior long-term patency compared with saphenous vein grafts.

A recent advance has been the "beating heart bypass".

Front 8

Coronary angioplasty

Back 8

Nonsurgical myocardial revascularization performed under fluoroscopic (x-ray) guidance in the cardiac catheterization laboratory.

Balloon inflation within the stenotic lesion results in splitting of the intimal plaque and subsequent stretching of the outer media and adventitia. The end result of this controlled injury is the distention of the outer arterial diameter and an enlarged internal lumen within the diseased segment which provides greater coronary blood flow.

In selected patients, plaque removal may be performed in conjunction with the PTCA.

Front 9

What is the rate of successful percutaneous transluminal coronary angioplasty dilatation?

Back 9

Over 95% of routine cases

Front 10

What is the rate of restenosis within 6 months following balloon angioplasty along?

Back 10

30-40%

Front 11

Prinzmetal's angina

Back 11

Variant angina; A clinical syndrome characterized by angina occurring at rest and associated with transient ST segment elevation of the ECG.

Pathophysiologic mechanism is intermittent coronary artery spasm.

Managed medically with coronary vasodilators nitroglycerin and calcium channel blockers. Beta adrenergic blockers are contraindicated.

Front 12

Nitroglycerin

Back 12

Reduces myocardial wall stress. The primary effect is the dilatation of peripheral veins which leads to a reduction in venous return; the reduction in ventricular filling (decreased preload) reduces the ventricular chamber size and, therefore, wall stress. In addition, dilatation of systemic arteries results in a reduction in systemic blood pressure and, therefore, an additional effect in reducing systolic wall stress. It also dilates the epicardial coronary arteries and is, therefore, effective in normalizing coronary flood flow in patients with coronary artery vasospasm.

Sublingual tablets or sprays are used for acute episodes of angina. Long-acting nitrates are also available in the form of pills, topical paste or patches which are used prophylactically to prevent anginal episodes.

Front 13

Beta adrenergic blockers

Back 13

Competitive blockade of sympathetic beta receptors in the heart. Beta blockade results in reduction of heart rate, reduction in myocardial contractility, and reduction in wall stress via a reduction in systolic blood pressure.

Front 14

Calcium channel blockers

Back 14

Calcium plays a critical role in the genesis of cardiac electrical excitation and in the mechanical contraction of both myocardial and vascular smooth muscle cells. These agents have the ability to reduce the influx of calcium into myocardial cells and vascular smooth muscle by blocking the activation of the "slow channels".

The common effect of all calcium channel blockers is the dilatation of both peripheral and coronary arteries.

Front 15

What transient cardiac auscultation abnormalities may be present during an episode of angina?

Back 15

S4 gallop (myocardium becomes stiffer) and mitral regurgitation (due to ischemia of papillary muscle)