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MYOCARDIAL MYOCARDIAL ISCHEMIC ISCHEMIC DISORDERS DISORDERS CORONARY ARTERY CORONARY ARTERY DISEASE (CAD) DISEASE (CAD)

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Page 1: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

MYOCARDIAL MYOCARDIAL ISCHEMIC ISCHEMIC

DISORDERSDISORDERS

MYOCARDIAL MYOCARDIAL ISCHEMIC ISCHEMIC

DISORDERSDISORDERS

CORONARY ARTERY CORONARY ARTERY DISEASE (CAD)DISEASE (CAD)

CORONARY ARTERY CORONARY ARTERY DISEASE (CAD)DISEASE (CAD)

Page 2: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Coronary artery disease is the

most common form of heart

disease and the single most

important cause of premature

death in the developed world.

Coronary artery disease is the

most common form of heart

disease and the single most

important cause of premature

death in the developed world.

Page 3: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Disease of the coronary arteries Disease of the coronary arteries is almost always due to is almost always due to

atheroma and its complications atheroma and its complications

thrombosisthrombosis

Disease of the coronary arteries Disease of the coronary arteries is almost always due to is almost always due to

atheroma and its complications atheroma and its complications

thrombosisthrombosis

Page 4: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Occasionally the coronary arteries Occasionally the coronary arteries

are involved in other disorders:are involved in other disorders: congenital anomalies (anomalous origin, congenital anomalies (anomalous origin,

fistula or malformation of a major coronary fistula or malformation of a major coronary

artery)artery)

aortitisaortitis

polyarteritispolyarteritis

and other connective tissue disorders and other connective tissue disorders

Occasionally the coronary arteries Occasionally the coronary arteries

are involved in other disorders:are involved in other disorders: congenital anomalies (anomalous origin, congenital anomalies (anomalous origin,

fistula or malformation of a major coronary fistula or malformation of a major coronary

artery)artery)

aortitisaortitis

polyarteritispolyarteritis

and other connective tissue disorders and other connective tissue disorders

Page 5: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ATHEROMA = ATHEROMA = ARTHEROSCLEROSISARTHEROSCLEROSIS

ATHEROMA = ATHEROMA = ARTHEROSCLEROSISARTHEROSCLEROSIS

a patchy focal disease of the arterial walla patchy focal disease of the arterial wall

Some arteries such as the coronary and Some arteries such as the coronary and cerebral are at high risk, while others cerebral are at high risk, while others

(e.g. radial artery and the internal (e.g. radial artery and the internal mammary artery) are largely spared.mammary artery) are largely spared.

a patchy focal disease of the arterial walla patchy focal disease of the arterial wall

Some arteries such as the coronary and Some arteries such as the coronary and cerebral are at high risk, while others cerebral are at high risk, while others

(e.g. radial artery and the internal (e.g. radial artery and the internal mammary artery) are largely spared.mammary artery) are largely spared.

Page 6: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Coronary artery, cerebral and Coronary artery, cerebral and

peripheral vascular disease often peripheral vascular disease often

coexist but seldom develop at the coexist but seldom develop at the

same ratesame rate..

Coronary artery, cerebral and Coronary artery, cerebral and

peripheral vascular disease often peripheral vascular disease often

coexist but seldom develop at the coexist but seldom develop at the

same ratesame rate..

Page 7: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The evolution of an atheromatous plaThe evolution of an atheromatous plaqqueueThe evolution of an atheromatous plaThe evolution of an atheromatous plaqqueue

Fatty Fatty streakstreak

Transitonal Transitonal plaqueplaque

Mature Mature plaqueplaque

Ruptured Ruptured plaque with plaque with thrombus thrombus formationformation

Foam cells

Extracellular lipid

pool

Smooth muscle cells

Thrombus

Fibrous cap

Foam cells

Extracellular lipid

pool

Smooth muscle cells

Thrombus

Fibrous cap

Page 8: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Fatty streaks develop as circulating Fatty streaks develop as circulating

monocytes migrate into the intima, take monocytes migrate into the intima, take

up oxidisup oxidiseded low-density lipoprotein low-density lipoprotein

(LDL) from the plasma, and become (LDL) from the plasma, and become

lipid-laden foam cells.lipid-laden foam cells.

As these foam cells die and release their As these foam cells die and release their

contents, extracellular lipid pools appear.contents, extracellular lipid pools appear.

Fatty streaks develop as circulating Fatty streaks develop as circulating

monocytes migrate into the intima, take monocytes migrate into the intima, take

up oxidisup oxidiseded low-density lipoprotein low-density lipoprotein

(LDL) from the plasma, and become (LDL) from the plasma, and become

lipid-laden foam cells.lipid-laden foam cells.

As these foam cells die and release their As these foam cells die and release their

contents, extracellular lipid pools appear.contents, extracellular lipid pools appear.

Page 9: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Local and systemic factors will determine Local and systemic factors will determine

whether a fatty streak resolves or whether a fatty streak resolves or

progresses to an atheromatous lesion.progresses to an atheromatous lesion.

In early atheroma, smooth muscle cells In early atheroma, smooth muscle cells

migrate into and proliferate within the migrate into and proliferate within the

plaque.plaque.

As the lesion grows it encroaches into the As the lesion grows it encroaches into the

lumen of the vessel and erodes the media.lumen of the vessel and erodes the media.

Local and systemic factors will determine Local and systemic factors will determine

whether a fatty streak resolves or whether a fatty streak resolves or

progresses to an atheromatous lesion.progresses to an atheromatous lesion.

In early atheroma, smooth muscle cells In early atheroma, smooth muscle cells

migrate into and proliferate within the migrate into and proliferate within the

plaque.plaque.

As the lesion grows it encroaches into the As the lesion grows it encroaches into the

lumen of the vessel and erodes the media.lumen of the vessel and erodes the media.

Page 10: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

A mature fibrilipid plague has a core of A mature fibrilipid plague has a core of

extracellular lipid surrounded by smooth extracellular lipid surrounded by smooth

muscle cells and is separated from the lumen muscle cells and is separated from the lumen

by a cap of collagen-rich fibrous tissue.by a cap of collagen-rich fibrous tissue.

Such plaques may rupture or fissure, allowing Such plaques may rupture or fissure, allowing

blood to enter and disrupt the arterial wall; blood to enter and disrupt the arterial wall;

this may compromise the lumen of the vessel this may compromise the lumen of the vessel

and often precipitates thrombosis and local and often precipitates thrombosis and local

vasospasm.vasospasm.

A mature fibrilipid plague has a core of A mature fibrilipid plague has a core of

extracellular lipid surrounded by smooth extracellular lipid surrounded by smooth

muscle cells and is separated from the lumen muscle cells and is separated from the lumen

by a cap of collagen-rich fibrous tissue.by a cap of collagen-rich fibrous tissue.

Such plaques may rupture or fissure, allowing Such plaques may rupture or fissure, allowing

blood to enter and disrupt the arterial wall; blood to enter and disrupt the arterial wall;

this may compromise the lumen of the vessel this may compromise the lumen of the vessel

and often precipitates thrombosis and local and often precipitates thrombosis and local

vasospasm.vasospasm.

Page 11: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Plaque rupture may lead to rapid Plaque rupture may lead to rapid

growth of the lesion or occlusion of growth of the lesion or occlusion of

the vessel and is thought to be the the vessel and is thought to be the

cause of most acute coronary cause of most acute coronary

syndromes.syndromes.

Plaque rupture may lead to rapid Plaque rupture may lead to rapid

growth of the lesion or occlusion of growth of the lesion or occlusion of

the vessel and is thought to be the the vessel and is thought to be the

cause of most acute coronary cause of most acute coronary

syndromes.syndromes.

Page 12: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The number and state of evolution of The number and state of evolution of

plaques both increase with age, but plaques both increase with age, but

the rate of progression of the rate of progression of

individual plaques, even in the individual plaques, even in the

same patient, is very variable.same patient, is very variable.

The number and state of evolution of The number and state of evolution of

plaques both increase with age, but plaques both increase with age, but

the rate of progression of the rate of progression of

individual plaques, even in the individual plaques, even in the

same patient, is very variable.same patient, is very variable.

Page 13: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations

Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations

Clinical problemClinical problem

Stable anginaStable angina

Unstable anginaUnstable angina

Clinical problemClinical problem

Stable anginaStable angina

Unstable anginaUnstable angina

PathologyPathology

Ischaemia due to fixed atheromatous Ischaemia due to fixed atheromatous stenosis of one or more coronary stenosis of one or more coronary

arteriesarteries

Ischemia caused by dynamic Ischemia caused by dynamic obstruction of a coronary artery obstruction of a coronary artery

due to plaque rupture with due to plaque rupture with superimposed thrombosis and superimposed thrombosis and

spasmspasm

PathologyPathology

Ischaemia due to fixed atheromatous Ischaemia due to fixed atheromatous stenosis of one or more coronary stenosis of one or more coronary

arteriesarteries

Ischemia caused by dynamic Ischemia caused by dynamic obstruction of a coronary artery obstruction of a coronary artery

due to plaque rupture with due to plaque rupture with superimposed thrombosis and superimposed thrombosis and

spasmspasm

Page 14: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations

Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations

Clinical problemClinical problem

MyocardialMyocardial

infarctioninfarction

Heart failureHeart failure

Clinical problemClinical problem

MyocardialMyocardial

infarctioninfarction

Heart failureHeart failure

PathologyPathology

Acute occlusion of a coronary Acute occlusion of a coronary artery due to plaque rupture artery due to plaque rupture

and thrombosis and resulting in and thrombosis and resulting in myocardial necrosismyocardial necrosis

Myocardial dysfunction due to Myocardial dysfunction due to infarction or ischemiainfarction or ischemia

PathologyPathology

Acute occlusion of a coronary Acute occlusion of a coronary artery due to plaque rupture artery due to plaque rupture

and thrombosis and resulting in and thrombosis and resulting in myocardial necrosismyocardial necrosis

Myocardial dysfunction due to Myocardial dysfunction due to infarction or ischemiainfarction or ischemia

Page 15: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations

Coronary artery disease: Coronary artery disease: clinical manifestationsclinical manifestations

Clinical problemClinical problem

ArrhythmiaArrhythmia

Sudden deathSudden death

Clinical problemClinical problem

ArrhythmiaArrhythmia

Sudden deathSudden death

PathologyPathology

Altered conduction due to Altered conduction due to infarction or ischemiainfarction or ischemia

Ventricular arrhythmia, asystole Ventricular arrhythmia, asystole or massive myocardial or massive myocardial

infarctioninfarction

PathologyPathology

Altered conduction due to Altered conduction due to infarction or ischemiainfarction or ischemia

Ventricular arrhythmia, asystole Ventricular arrhythmia, asystole or massive myocardial or massive myocardial

infarctioninfarction

Page 16: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Some important risk factors for Some important risk factors for coronary artery diseasecoronary artery disease

Some important risk factors for Some important risk factors for coronary artery diseasecoronary artery disease

FixedFixed

AgeAge

Male sexMale sex

Family historyFamily history

FixedFixed

AgeAge

Male sexMale sex

Family historyFamily history

ModifiableModifiable SmokingSmoking

HypertensionHypertension Lipid disordersLipid disorders

Diabetes mellitusDiabetes mellitus Hemostatic variablesHemostatic variables

Sedentary lifestyleSedentary lifestyle Dietary deficiencies Dietary deficiencies

ModifiableModifiable SmokingSmoking

HypertensionHypertension Lipid disordersLipid disorders

Diabetes mellitusDiabetes mellitus Hemostatic variablesHemostatic variables

Sedentary lifestyleSedentary lifestyle Dietary deficiencies Dietary deficiencies

Page 17: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

„„New” risk factors for coronary New” risk factors for coronary artery diseaseartery disease

„„New” risk factors for coronary New” risk factors for coronary artery diseaseartery disease

HomocysteineHomocysteine

FibrinogenFibrinogen

Von Willebrand factorVon Willebrand factor

CRPCRP

Lp(a)Lp(a)

HomocysteineHomocysteine

FibrinogenFibrinogen

Von Willebrand factorVon Willebrand factor

CRPCRP

Lp(a)Lp(a)

Folic acid, Vit BFolic acid, Vit B1212, Vit B, Vit B66Folic acid, Vit BFolic acid, Vit B1212, Vit B, Vit B66

Page 18: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ANGINA PECTORISANGINA PECTORISANGINA PECTORISANGINA PECTORIS

A clinical syndrome due to A clinical syndrome due to

myocardial ischemia characterized myocardial ischemia characterized

by episodes of perby episodes of periicordial cordial

discomfort or pressure, typically discomfort or pressure, typically

precipitated by exertion and relived precipitated by exertion and relived

by rest or sublingual nitroglycerin.by rest or sublingual nitroglycerin.

A clinical syndrome due to A clinical syndrome due to

myocardial ischemia characterized myocardial ischemia characterized

by episodes of perby episodes of periicordial cordial

discomfort or pressure, typically discomfort or pressure, typically

precipitated by exertion and relived precipitated by exertion and relived

by rest or sublingual nitroglycerin.by rest or sublingual nitroglycerin.

Page 19: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ANGINA PECTORISANGINA PECTORISANGINA PECTORISANGINA PECTORIS

may occur whenever there may occur whenever there

is an imbalance between is an imbalance between

myocardial oxygen supply myocardial oxygen supply

and demand.and demand.

may occur whenever there may occur whenever there

is an imbalance between is an imbalance between

myocardial oxygen supply myocardial oxygen supply

and demand.and demand.

Page 20: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ANGINA PECTORISANGINA PECTORISANGINA PECTORISANGINA PECTORIS

Cause:Cause:

most common most common coronary atheromacoronary atheroma

but also:but also:

aortic valve diseaseaortic valve disease

hypertrophic cardiomyopathyhypertrophic cardiomyopathy

some other forms of heart diseasesome other forms of heart disease

Cause:Cause:

most common most common coronary atheromacoronary atheroma

but also:but also:

aortic valve diseaseaortic valve disease

hypertrophic cardiomyopathyhypertrophic cardiomyopathy

some other forms of heart diseasesome other forms of heart disease

Page 21: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical situations precipitating Clinical situations precipitating anginaangina

Clinical situations precipitating Clinical situations precipitating anginaangina

Common:Common: Physical exertionPhysical exertion

Cold exposureCold exposure Heavy mealsHeavy meals

Intense emotionIntense emotion

Common:Common: Physical exertionPhysical exertion

Cold exposureCold exposure Heavy mealsHeavy meals

Intense emotionIntense emotion

Rare:Rare: Lying flatLying flat

decubitus anginadecubitus angina Vivid dreamsVivid dreams

nocturnal anginanocturnal angina

Rare:Rare: Lying flatLying flat

decubitus anginadecubitus angina Vivid dreamsVivid dreams

nocturnal anginanocturnal angina

Page 22: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Stable angina is characterised Stable angina is characterised

typically by central chest typically by central chest

pain that is precipitated by pain that is precipitated by

exertion and promptly exertion and promptly

relived by restrelived by rest

Stable angina is characterised Stable angina is characterised

typically by central chest typically by central chest

pain that is precipitated by pain that is precipitated by

exertion and promptly exertion and promptly

relived by restrelived by rest

Page 23: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Most patients describe a sense of Most patients describe a sense of

oppression or tightness in the oppression or tightness in the

chestchest

„„like a band round the chest”like a band round the chest”;;

„„pain” may be deniedpain” may be denied

Most patients describe a sense of Most patients describe a sense of

oppression or tightness in the oppression or tightness in the

chestchest

„„like a band round the chest”like a band round the chest”;;

„„pain” may be deniedpain” may be denied

Page 24: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

When describing angina the victim often When describing angina the victim often

closes a hand around the throat, puts a closes a hand around the throat, puts a

hand or clenched fist on the sternum, or hand or clenched fist on the sternum, or

places both hands across the lower chest.places both hands across the lower chest.

Many patients report a „choking” Many patients report a „choking”

sensation.sensation.

Breathlessness is sometimes a prominent Breathlessness is sometimes a prominent

featurefeature..

When describing angina the victim often When describing angina the victim often

closes a hand around the throat, puts a closes a hand around the throat, puts a

hand or clenched fist on the sternum, or hand or clenched fist on the sternum, or

places both hands across the lower chest.places both hands across the lower chest.

Many patients report a „choking” Many patients report a „choking”

sensation.sensation.

Breathlessness is sometimes a prominent Breathlessness is sometimes a prominent

featurefeature..

Page 25: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The pain may radiate to:The pain may radiate to:

the left shoulder and down the inside of the left the left shoulder and down the inside of the left

arm, even to the fingers,arm, even to the fingers,

the necthe neckk,,

the jaw,the jaw,

the teeth,the teeth,

occasionally even down the right arm.occasionally even down the right arm.

Anginal discomfort may be felt in the upper Anginal discomfort may be felt in the upper

abdomen.abdomen.

The pain may radiate to:The pain may radiate to:

the left shoulder and down the inside of the left the left shoulder and down the inside of the left

arm, even to the fingers,arm, even to the fingers,

the necthe neckk,,

the jaw,the jaw,

the teeth,the teeth,

occasionally even down the right arm.occasionally even down the right arm.

Anginal discomfort may be felt in the upper Anginal discomfort may be felt in the upper

abdomen.abdomen.

Page 26: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Attacks may vary in frequency from Attacks may vary in frequency from several/day to several/day to ooccasional episodes separated ccasional episodes separated by symptom-free intervals of weeks, months, by symptom-free intervals of weeks, months,

or years.or years.

They may increase in frequency (crescendo They may increase in frequency (crescendo angina) to a fatal outcome or may gradually angina) to a fatal outcome or may gradually

decrease or disappear if an adequate decrease or disappear if an adequate collateral coronary circulation develops, if collateral coronary circulation develops, if the ischemic area becomes infarcted, or if the ischemic area becomes infarcted, or if

heart failure supervenes and limits activityheart failure supervenes and limits activity..

Attacks may vary in frequency from Attacks may vary in frequency from several/day to several/day to ooccasional episodes separated ccasional episodes separated by symptom-free intervals of weeks, months, by symptom-free intervals of weeks, months,

or years.or years.

They may increase in frequency (crescendo They may increase in frequency (crescendo angina) to a fatal outcome or may gradually angina) to a fatal outcome or may gradually

decrease or disappear if an adequate decrease or disappear if an adequate collateral coronary circulation develops, if collateral coronary circulation develops, if the ischemic area becomes infarcted, or if the ischemic area becomes infarcted, or if

heart failure supervenes and limits activityheart failure supervenes and limits activity..

Page 27: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Any change in the pattern of symptoms:Any change in the pattern of symptoms:Any change in the pattern of symptoms:Any change in the pattern of symptoms:

increased intensity of attacksincreased intensity of attacks decreased threshold of stimulusdecreased threshold of stimulus

longer durationlonger duration occurrence when patient is sedentary or occurrence when patient is sedentary or

awakening from sleepawakening from sleep

unstable angina pectoris = unstable angina pectoris = acute coronary insufficiency = acute coronary insufficiency =

preinfarction anginapreinfarction angina

increased intensity of attacksincreased intensity of attacks decreased threshold of stimulusdecreased threshold of stimulus

longer durationlonger duration occurrence when patient is sedentary or occurrence when patient is sedentary or

awakening from sleepawakening from sleep

unstable angina pectoris = unstable angina pectoris = acute coronary insufficiency = acute coronary insufficiency =

preinfarction anginapreinfarction angina

Page 28: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Stable anginaStable anginais relis relaated to a fixed ted to a fixed

obstruction and obstruction and

usually precipitated usually precipitated

by an increase in by an increase in

myocardial oxygen myocardial oxygen

demanddemand

demand-led ischaemiademand-led ischaemia

Stable anginaStable anginais relis relaated to a fixed ted to a fixed

obstruction and obstruction and

usually precipitated usually precipitated

by an increase in by an increase in

myocardial oxygen myocardial oxygen

demanddemand

demand-led ischaemiademand-led ischaemia

Unstable anginaUnstable anginais due to an abrupt is due to an abrupt

reduction in reduction in

coronary blood flow coronary blood flow

caused by thrombosis caused by thrombosis

or spasmor spasm

ssupply-led ischaemiaupply-led ischaemia

Unstable anginaUnstable anginais due to an abrupt is due to an abrupt

reduction in reduction in

coronary blood flow coronary blood flow

caused by thrombosis caused by thrombosis

or spasmor spasm

ssupply-led ischaemiaupply-led ischaemia

Page 29: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Unstable angina may be prodromal Unstable angina may be prodromal

to acute MI;to acute MI;

Sudden death is less commonSudden death is less common

Prospective studies suggest that ~30% of Prospective studies suggest that ~30% of

patients with unstable angina will patients with unstable angina will

suffer an MI within 3 months of onset.suffer an MI within 3 months of onset.

Unstable angina may be prodromal Unstable angina may be prodromal

to acute MI;to acute MI;

Sudden death is less commonSudden death is less common

Prospective studies suggest that ~30% of Prospective studies suggest that ~30% of

patients with unstable angina will patients with unstable angina will

suffer an MI within 3 months of onset.suffer an MI within 3 months of onset.

Page 30: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Physical findingsPhysical findings

Between and even during attacks, there Between and even during attacks, there

may be no signs of organic heart disease.may be no signs of organic heart disease.

However, during the attack, heart rate However, during the attack, heart rate

may increase modestly, BP is often may increase modestly, BP is often

elevated, heart sounds become more elevated, heart sounds become more

distant, and the apical impulse is more distant, and the apical impulse is more

diffuse.diffuse.

Between and even during attacks, there Between and even during attacks, there

may be no signs of organic heart disease.may be no signs of organic heart disease.

However, during the attack, heart rate However, during the attack, heart rate

may increase modestly, BP is often may increase modestly, BP is often

elevated, heart sounds become more elevated, heart sounds become more

distant, and the apical impulse is more distant, and the apical impulse is more

diffuse.diffuse.

Page 31: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Physical findingsPhysical findings

Palpation of the precordium may Palpation of the precordium may

reveal a localized systolic bulging or reveal a localized systolic bulging or

paradoxical movement reflecting paradoxical movement reflecting

segmental myocardial ischaemia and segmental myocardial ischaemia and

regional dyskinesia. regional dyskinesia.

Palpation of the precordium may Palpation of the precordium may

reveal a localized systolic bulging or reveal a localized systolic bulging or

paradoxical movement reflecting paradoxical movement reflecting

segmental myocardial ischaemia and segmental myocardial ischaemia and

regional dyskinesia. regional dyskinesia.

Page 32: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Physical findingsPhysical findings

The 2nd heart sound may become The 2nd heart sound may become

paradoxical because of more paradoxical because of more

prolonged LV ejection during the prolonged LV ejection during the

ischaemia episode.ischaemia episode.

A 4th heart sound is common. A 4th heart sound is common.

The 2nd heart sound may become The 2nd heart sound may become

paradoxical because of more paradoxical because of more

prolonged LV ejection during the prolonged LV ejection during the

ischaemia episode.ischaemia episode.

A 4th heart sound is common. A 4th heart sound is common.

Page 33: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Physical findingsPhysical findings

A mid- or late-systolic apical A mid- or late-systolic apical

murmur, rather shrill but not murmur, rather shrill but not

especially loud, due to localized especially loud, due to localized

papillary muscle dysfunction papillary muscle dysfunction

secondary to the ischaemia may secondary to the ischaemia may

occur. occur.

A mid- or late-systolic apical A mid- or late-systolic apical

murmur, rather shrill but not murmur, rather shrill but not

especially loud, due to localized especially loud, due to localized

papillary muscle dysfunction papillary muscle dysfunction

secondary to the ischaemia may secondary to the ischaemia may

occur. occur.

Page 34: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

DiagnosisDiagnosisDiagnosisDiagnosis Angina pectoris is a clinical diagnosis based Angina pectoris is a clinical diagnosis based

on a characteristic complaint of chest on a characteristic complaint of chest discomfortdiscomfort brought on by exertion and brought on by exertion and

relieved by rest.relieved by rest. Confirmation may be obtained by observing Confirmation may be obtained by observing

reversible ECG changes during a reversible ECG changes during a spontaneous attack or by giving a test dose spontaneous attack or by giving a test dose

of sublingual nitroglycerin that of sublingual nitroglycerin that characteristically relives the pain within 1.5 characteristically relives the pain within 1.5

to 3 min.to 3 min.

Angina pectoris is a clinical diagnosis based Angina pectoris is a clinical diagnosis based on a characteristic complaint of chest on a characteristic complaint of chest

discomfortdiscomfort brought on by exertion and brought on by exertion and relieved by rest.relieved by rest.

Confirmation may be obtained by observing Confirmation may be obtained by observing reversible ECG changes during a reversible ECG changes during a

spontaneous attack or by giving a test dose spontaneous attack or by giving a test dose of sublingual nitroglycerin that of sublingual nitroglycerin that

characteristically relives the pain within 1.5 characteristically relives the pain within 1.5 to 3 min.to 3 min.

Page 35: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

DiagnosisDiagnosisDiagnosisDiagnosis

An abnormal resting ECG alone does An abnormal resting ECG alone does

not establish or refute the diagnosis not establish or refute the diagnosis

of angina pectoris, which must be of angina pectoris, which must be

recognized from characteristic recognized from characteristic

symptoms.symptoms.

An abnormal resting ECG alone does An abnormal resting ECG alone does

not establish or refute the diagnosis not establish or refute the diagnosis

of angina pectoris, which must be of angina pectoris, which must be

recognized from characteristic recognized from characteristic

symptoms.symptoms.

Page 36: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

DiagnosisDiagnosisDiagnosisDiagnosis

Several diagnostic tests are availableSeveral diagnostic tests are available

Exercise tolerance testing or radionuclide Exercise tolerance testing or radionuclide

imaging durinimaging duringg stress and after rest can stress and after rest can

establish the presence of ischaemia, but false establish the presence of ischaemia, but false

– positives and –negatives occur.– positives and –negatives occur.

Several diagnostic tests are availableSeveral diagnostic tests are available

Exercise tolerance testing or radionuclide Exercise tolerance testing or radionuclide

imaging durinimaging duringg stress and after rest can stress and after rest can

establish the presence of ischaemia, but false establish the presence of ischaemia, but false

– positives and –negatives occur.– positives and –negatives occur.

Page 37: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

DiagnosisDiagnosisDiagnosisDiagnosis

Coronary arteriography Coronary arteriography

documents coronary documents coronary

obstruction in the epicardial obstruction in the epicardial

vessels due to CAD.vessels due to CAD.

Coronary arteriography Coronary arteriography

documents coronary documents coronary

obstruction in the epicardial obstruction in the epicardial

vessels due to CAD.vessels due to CAD.

Page 38: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ECGECGECGECG Typically ST segment depressionTypically ST segment depression

ST segment elevationST segment elevation decrease in R wave heightdecrease in R wave height

intrintraaventricular or bundle branch ventricular or bundle branch conduction disturbancesconduction disturbances

arrhythmia (ventricular extrasystoles)arrhythmia (ventricular extrasystoles)

Typically ST segment depressionTypically ST segment depression ST segment elevationST segment elevation

decrease in R wave heightdecrease in R wave height intrintraaventricular or bundle branch ventricular or bundle branch

conduction disturbancesconduction disturbances arrhythmia (ventricular extrasystoles)arrhythmia (ventricular extrasystoles)

Page 39: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ECGECGECGECG Between episodes, the ECG Between episodes, the ECG

at rest is normal in ~30% of at rest is normal in ~30% of

patients with a typical patients with a typical

history of angina pectoris, history of angina pectoris,

even in extensive 3-vessel even in extensive 3-vessel

CAD.CAD.

Between episodes, the ECG Between episodes, the ECG

at rest is normal in ~30% of at rest is normal in ~30% of

patients with a typical patients with a typical

history of angina pectoris, history of angina pectoris,

even in extensive 3-vessel even in extensive 3-vessel

CAD.CAD.

Page 40: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The components of an ECG complexThe components of an ECG complexThe components of an ECG complexThe components of an ECG complex

Page 41: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Forms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depression

Planar ST depressionPlanar ST depression

(( 1mm) 1mm)

Planar ST depressionPlanar ST depression

(( 1mm) 1mm)

Page 42: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Downsloping depressionDownsloping depression

(( 1mm) 1mm)

Downsloping depressionDownsloping depression

(( 1mm) 1mm)

Forms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depression

Page 43: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Upsloping depression Upsloping depression

(may be a normal finding!)(may be a normal finding!)

Upsloping depression Upsloping depression

(may be a normal finding!)(may be a normal finding!)

Forms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depressionForms of exercise-induced ST depression

Page 44: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

A positive A positive exercise testexercise test

Page 45: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

A positive A positive exercise testexercise test

Page 46: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

MYOCARDIAL MYOCARDIAL

INFRACTIONINFRACTION

MYOCARDIAL MYOCARDIAL

INFRACTIONINFRACTION

MI is almost always due to the MI is almost always due to the

formation of occlusive thrombus at formation of occlusive thrombus at

the site of rupture of an the site of rupture of an

atheromatous plaque in a coronary atheromatous plaque in a coronary

artery.artery.

MI is almost always due to the MI is almost always due to the

formation of occlusive thrombus at formation of occlusive thrombus at

the site of rupture of an the site of rupture of an

atheromatous plaque in a coronary atheromatous plaque in a coronary

artery.artery.

Page 47: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Coronary artery thrombosisCoronary artery thrombosisCoronary artery thrombosisCoronary artery thrombosis

lipid poollipid poolintraintimal

thrombosis

intraintimal

thrombosis

intraluminal

thrombosis

intraluminal

thrombosispropagating

thrombosis

propagating

thrombosis

Page 48: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The thrombus is often undergoes The thrombus is often undergoes

spontaneous lysis over the course spontaneous lysis over the course

of the next few days, although by of the next few days, although by

this time irreversible myocardial this time irreversible myocardial

damage has occurred.damage has occurred.

The thrombus is often undergoes The thrombus is often undergoes

spontaneous lysis over the course spontaneous lysis over the course

of the next few days, although by of the next few days, although by

this time irreversible myocardial this time irreversible myocardial

damage has occurred.damage has occurred.

Page 49: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The time course of myocardial infarctionThe time course of myocardial infarctionThe time course of myocardial infarctionThe time course of myocardial infarction

The relative proportion of ischaemic, infarcting and The relative proportion of ischaemic, infarcting and infarcted tissue slowly changes over a period of infarcted tissue slowly changes over a period of 8 – 8 –

12 hours. In the early stages of myocardial infarction 12 hours. In the early stages of myocardial infarction a significant proportion of the myocardium in a significant proportion of the myocardium in

jeopardy is potentially salvageablejeopardy is potentially salvageable..

The relative proportion of ischaemic, infarcting and The relative proportion of ischaemic, infarcting and infarcted tissue slowly changes over a period of infarcted tissue slowly changes over a period of 8 – 8 –

12 hours. In the early stages of myocardial infarction 12 hours. In the early stages of myocardial infarction a significant proportion of the myocardium in a significant proportion of the myocardium in

jeopardy is potentially salvageablejeopardy is potentially salvageable..

Page 50: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Myocardial infarction-Myocardial infarction-clinical featuresclinical features

Myocardial infarction-Myocardial infarction-clinical featuresclinical features

Some 2/3 of patients experience Some 2/3 of patients experience

prodromal symptoms days to prodromal symptoms days to

weeks before the event, weeks before the event,

characterized by crescendo characterized by crescendo

angina, shortness of breath, or angina, shortness of breath, or

fatigue.fatigue.

Some 2/3 of patients experience Some 2/3 of patients experience

prodromal symptoms days to prodromal symptoms days to

weeks before the event, weeks before the event,

characterized by crescendo characterized by crescendo

angina, shortness of breath, or angina, shortness of breath, or

fatigue.fatigue.

Page 51: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical featuresClinical features

Cardinal symptom:Cardinal symptom:

painpain

breathlessnessbreathlessness vomitingvomiting collapse or collapse or

syncopesyncope

Cardinal symptom:Cardinal symptom:

painpain

breathlessnessbreathlessness vomitingvomiting collapse or collapse or

syncopesyncope

common

symptoms

common

symptoms

Page 52: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The pain occurs in the same sites as angina The pain occurs in the same sites as angina

but is usually more severe and lasts but is usually more severe and lasts

longer; it is often described as a tightness, longer; it is often described as a tightness,

heaviness or constriction in the chest.heaviness or constriction in the chest.

At its worst the pain is one of the most At its worst the pain is one of the most

severe which can be experienced and the severe which can be experienced and the

patient’s expression and pallor may patient’s expression and pallor may

vividly convey the seriousness of the vividly convey the seriousness of the

situationsituation..

The pain occurs in the same sites as angina The pain occurs in the same sites as angina

but is usually more severe and lasts but is usually more severe and lasts

longer; it is often described as a tightness, longer; it is often described as a tightness,

heaviness or constriction in the chest.heaviness or constriction in the chest.

At its worst the pain is one of the most At its worst the pain is one of the most

severe which can be experienced and the severe which can be experienced and the

patient’s expression and pallor may patient’s expression and pallor may

vividly convey the seriousness of the vividly convey the seriousness of the

situationsituation..

Page 53: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Deep, substernal, visceral, long lasting Deep, substernal, visceral, long lasting

pain described as aching or pressure, pain described as aching or pressure,

with radiation to the back, jaw, or with radiation to the back, jaw, or

left armleft arm

MIMI

Deep, substernal, visceral, long lasting Deep, substernal, visceral, long lasting

pain described as aching or pressure, pain described as aching or pressure,

with radiation to the back, jaw, or with radiation to the back, jaw, or

left armleft arm

MIMI

Page 54: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Most patients are breathless and in some Most patients are breathless and in some

this is the only symptom.this is the only symptom.

If syncope occurs it is usually due to an If syncope occurs it is usually due to an

arrhythmia or profound hypotension.arrhythmia or profound hypotension.

Vomiting and sinus bradycardia are often Vomiting and sinus bradycardia are often

due to vagal stimulation and are due to vagal stimulation and are

particularly common in patients with particularly common in patients with

inferior myocardial infraction.inferior myocardial infraction.

Most patients are breathless and in some Most patients are breathless and in some

this is the only symptom.this is the only symptom.

If syncope occurs it is usually due to an If syncope occurs it is usually due to an

arrhythmia or profound hypotension.arrhythmia or profound hypotension.

Vomiting and sinus bradycardia are often Vomiting and sinus bradycardia are often

due to vagal stimulation and are due to vagal stimulation and are

particularly common in patients with particularly common in patients with

inferior myocardial infraction.inferior myocardial infraction.

Page 55: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Symptoms of LV failure, Symptoms of LV failure,

pulmonary pulmonary ooedema, shock, or edema, shock, or

significant arrhythmia may significant arrhythmia may

develop and dominant the develop and dominant the

clinical picture. clinical picture.

Symptoms of LV failure, Symptoms of LV failure,

pulmonary pulmonary ooedema, shock, or edema, shock, or

significant arrhythmia may significant arrhythmia may

develop and dominant the develop and dominant the

clinical picture. clinical picture.

Page 56: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

However, discomfort may be However, discomfort may be

very mild, and a significant very mild, and a significant

percentage (~20%) of acute percentage (~20%) of acute

MIs are silent or unrecognized MIs are silent or unrecognized

as illness by the patient.as illness by the patient.

However, discomfort may be However, discomfort may be

very mild, and a significant very mild, and a significant

percentage (~20%) of acute percentage (~20%) of acute

MIs are silent or unrecognized MIs are silent or unrecognized

as illness by the patient.as illness by the patient.

Page 57: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

On examination:On examination:On examination:On examination:

The patient is usually:The patient is usually: restlessrestless

apprehensiveapprehensive palepale

diaphoreticdiaphoretic and in severe painand in severe pain

The patient is usually:The patient is usually: restlessrestless

apprehensiveapprehensive palepale

diaphoreticdiaphoretic and in severe painand in severe pain

Page 58: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

On examination:On examination:On examination:On examination:

the skin is usually coldthe skin is usually cold

peripheral or central peripheral or central

cyanosis may be cyanosis may be

appappaarentrent

the skin is usually coldthe skin is usually cold

peripheral or central peripheral or central

cyanosis may be cyanosis may be

appappaarentrent

Page 59: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

On examination:On examination:On examination:On examination:

the pulse may be threadythe pulse may be thready

the BP is variably, although the BP is variably, although

many patients initially manifest many patients initially manifest

some degree of hypertension some degree of hypertension

unless cardiogenic shock is unless cardiogenic shock is

developingdeveloping

the pulse may be threadythe pulse may be thready

the BP is variably, although the BP is variably, although

many patients initially manifest many patients initially manifest

some degree of hypertension some degree of hypertension

unless cardiogenic shock is unless cardiogenic shock is

developingdeveloping

Page 60: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

On examination:On examination:On examination:On examination:

Arrhythmia is common:Arrhythmia is common:

bradycardiabradycardia

extrasystolesextrasystoles

ventricular fibrillationventricular fibrillation

Arrhythmia is common:Arrhythmia is common:

bradycardiabradycardia

extrasystolesextrasystoles

ventricular fibrillationventricular fibrillation

Page 61: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

On examination:On examination:On examination:On examination:

The heart sounds are usually The heart sounds are usually

somewhat distantsomewhat distant

the presence of 4th heart the presence of 4th heart

sound is almost universalsound is almost universal

The heart sounds are usually The heart sounds are usually

somewhat distantsomewhat distant

the presence of 4th heart the presence of 4th heart

sound is almost universalsound is almost universal

Page 62: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

On examination:On examination:On examination:On examination:

There may be a soft systolic blowing apical There may be a soft systolic blowing apical

murmur (a reflection of papillary muscle murmur (a reflection of papillary muscle

dysfunction)dysfunction)

At initial evaluation, the presence of a At initial evaluation, the presence of a

friction rub or more striking murmurs friction rub or more striking murmurs

suggests the possibility of preexisting heart suggests the possibility of preexisting heart

disease or another diagnosisdisease or another diagnosis

There may be a soft systolic blowing apical There may be a soft systolic blowing apical

murmur (a reflection of papillary muscle murmur (a reflection of papillary muscle

dysfunction)dysfunction)

At initial evaluation, the presence of a At initial evaluation, the presence of a

friction rub or more striking murmurs friction rub or more striking murmurs

suggests the possibility of preexisting heart suggests the possibility of preexisting heart

disease or another diagnosisdisease or another diagnosis

Page 63: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Detection of friction rub within a few hours Detection of friction rub within a few hours

after the onset of symptoms of acute MI after the onset of symptoms of acute MI

is distinctly unusual and might suggest is distinctly unusual and might suggest

a diagnosis of acute pericarditis rather a diagnosis of acute pericarditis rather

than MI.than MI.

Friction rubs, usually evanescent, are Friction rubs, usually evanescent, are

common on days 2 and 3 post infarction common on days 2 and 3 post infarction

with transmural infarctswith transmural infarcts

Detection of friction rub within a few hours Detection of friction rub within a few hours

after the onset of symptoms of acute MI after the onset of symptoms of acute MI

is distinctly unusual and might suggest is distinctly unusual and might suggest

a diagnosis of acute pericarditis rather a diagnosis of acute pericarditis rather

than MI.than MI.

Friction rubs, usually evanescent, are Friction rubs, usually evanescent, are

common on days 2 and 3 post infarction common on days 2 and 3 post infarction

with transmural infarctswith transmural infarcts

Page 64: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

MI MI physical signs physical signs MI MI physical signs physical signs

Signs of sympathetic Signs of sympathetic activation:activation: pallorpallor

sweatingsweating tachycardiatachycardia

Signs of vagal Signs of vagal activation:activation:

vomitingvomiting bradycardiabradycardia

Signs of sympathetic Signs of sympathetic activation:activation: pallorpallor

sweatingsweating tachycardiatachycardia

Signs of vagal Signs of vagal activation:activation:

vomitingvomiting bradycardiabradycardia

Signs of tissue Signs of tissue

damage:damage:

feverfever

Signs of Signs of

complicationscomplications

mitral regurgitationmitral regurgitation

pericarditispericarditis

Signs of tissue Signs of tissue

damage:damage:

feverfever

Signs of Signs of

complicationscomplications

mitral regurgitationmitral regurgitation

pericarditispericarditis

Page 65: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

MI MI physical signs physical signs MI MI physical signs physical signs

hypotension,hypotension, oliguria, oliguria,

cold peripheriescold peripheries narrow pulse narrow pulse

pressurepressure raised JPVraised JPV

hypotension,hypotension, oliguria, oliguria,

cold peripheriescold peripheries narrow pulse narrow pulse

pressurepressure raised JPVraised JPV

third heart soundthird heart sound

quiet first heart quiet first heart

soundsound

diffuse apical diffuse apical

impulseimpulse

lung crepitationslung crepitations

third heart soundthird heart sound

quiet first heart quiet first heart

soundsound

diffuse apical diffuse apical

impulseimpulse

lung crepitationslung crepitations

Signs of impaired myocardial function:Signs of impaired myocardial function:

Page 66: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Sudden death, from ventricular Sudden death, from ventricular

fibrillation or asystole, may occur fibrillation or asystole, may occur

immediately, and many deaths occur immediately, and many deaths occur

within the first hour.within the first hour.

The development of cardiac failure The development of cardiac failure

reflects the extent of myocardial damage reflects the extent of myocardial damage

and is the major cause of death in those and is the major cause of death in those

who survive the first few hours of MIwho survive the first few hours of MI..

Sudden death, from ventricular Sudden death, from ventricular

fibrillation or asystole, may occur fibrillation or asystole, may occur

immediately, and many deaths occur immediately, and many deaths occur

within the first hour.within the first hour.

The development of cardiac failure The development of cardiac failure

reflects the extent of myocardial damage reflects the extent of myocardial damage

and is the major cause of death in those and is the major cause of death in those

who survive the first few hours of MIwho survive the first few hours of MI..

Page 67: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

LABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGS

The most important The most important

laboratory procedure in laboratory procedure in

the patient with suspected the patient with suspected

acute MI is analysis of the acute MI is analysis of the

ECG.ECG.

The most important The most important

laboratory procedure in laboratory procedure in

the patient with suspected the patient with suspected

acute MI is analysis of the acute MI is analysis of the

ECG.ECG.

Page 68: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

LABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGSLABORATORY FINDINGS

The ECG is usually a sensitive and specific The ECG is usually a sensitive and specific

way to confirming the diagnosis; however, it way to confirming the diagnosis; however, it

may be difficult to interpret if there is bundle may be difficult to interpret if there is bundle

branch block or evidence of previous branch block or evidence of previous

myocardial infarction.myocardial infarction.

Occasionally the initial ECG is normal and Occasionally the initial ECG is normal and

diagnostic changes appear a few hours later.diagnostic changes appear a few hours later.

The ECG is usually a sensitive and specific The ECG is usually a sensitive and specific

way to confirming the diagnosis; however, it way to confirming the diagnosis; however, it

may be difficult to interpret if there is bundle may be difficult to interpret if there is bundle

branch block or evidence of previous branch block or evidence of previous

myocardial infarction.myocardial infarction.

Occasionally the initial ECG is normal and Occasionally the initial ECG is normal and

diagnostic changes appear a few hours later.diagnostic changes appear a few hours later.

Page 69: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MI

B:B: Acute ST elevation („the Acute ST elevation („the current of injury”)current of injury”)

C:C: Progressive loss of the R Progressive loss of the R wave, developing Q wave, wave, developing Q wave, resolution of the ST elevation resolution of the ST elevation and terminal T wave and terminal T wave inversioninversion

D:D: Deep Q wave and T wave Deep Q wave and T wave inversioninversion

E:E: Old or established infarct Old or established infarct pattern – the Q wave tends pattern – the Q wave tends to persist but the T wave to persist but the T wave changes become less markedchanges become less marked

B:B: Acute ST elevation („the Acute ST elevation („the current of injury”)current of injury”)

C:C: Progressive loss of the R Progressive loss of the R wave, developing Q wave, wave, developing Q wave, resolution of the ST elevation resolution of the ST elevation and terminal T wave and terminal T wave inversioninversion

D:D: Deep Q wave and T wave Deep Q wave and T wave inversioninversion

E:E: Old or established infarct Old or established infarct pattern – the Q wave tends pattern – the Q wave tends to persist but the T wave to persist but the T wave changes become less markedchanges become less marked

A: Normal ECG complexA: Normal ECG complex

Page 70: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MIThe serial evolution of ECG changes in full thickness MI

B:B: stage B appears within stage B appears within

minutesminutes

C:C: within hours within hours

D:D: within days within days

E:E: after several weeks or after several weeks or

monthsmonths

B:B: stage B appears within stage B appears within

minutesminutes

C:C: within hours within hours

D:D: within days within days

E:E: after several weeks or after several weeks or

monthsmonths

The rate of evolution is

very variable; in general:

The rate of evolution is

very variable; in general:

Page 71: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

In contrast to transmural lesion, In contrast to transmural lesion,

subendocardial infarction causes ST/T subendocardial infarction causes ST/T

wave changes without Q waves or wave changes without Q waves or

prominent ST elevation; this is often prominent ST elevation; this is often

accompanied by some loss of the R waves accompanied by some loss of the R waves

in the lein the leaads facing the infarct.ds facing the infarct.

In contrast to transmural lesion, In contrast to transmural lesion,

subendocardial infarction causes ST/T subendocardial infarction causes ST/T

wave changes without Q waves or wave changes without Q waves or

prominent ST elevation; this is often prominent ST elevation; this is often

accompanied by some loss of the R waves accompanied by some loss of the R waves

in the lein the leaads facing the infarct.ds facing the infarct.

Page 72: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Recent anterior Recent anterior

subendocardial subendocardial

(partial thickness) (partial thickness)

infarctioninfarction

Recent anterior Recent anterior

subendocardial subendocardial

(partial thickness) (partial thickness)

infarctioninfarction

There is deep There is deep

symmetrical T wave symmetrical T wave

inversion together inversion together

with a reduction in with a reduction in

the height of the R the height of the R

wave in leads Vwave in leads V11, V, V22, ,

VV33 and V and V44..

There is deep There is deep

symmetrical T wave symmetrical T wave

inversion together inversion together

with a reduction in with a reduction in

the height of the R the height of the R

wave in leads Vwave in leads V11, V, V22, ,

VV33 and V and V44..

Page 73: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The ECG changes are best seen in the leads which The ECG changes are best seen in the leads which „face” the infarcted area.„face” the infarcted area.

The ECG changes are best seen in the leads which The ECG changes are best seen in the leads which „face” the infarcted area.„face” the infarcted area.

Anteroseptal infarctionAnteroseptal infarction

Anterolateral infarctionAnterolateral infarction

Inferior infarctionInferior infarction

Posterior infarctionPosterior infarction

Anteroseptal infarctionAnteroseptal infarction

Anterolateral infarctionAnterolateral infarction

Inferior infarctionInferior infarction

Posterior infarctionPosterior infarction

one or more leads from Vone or more leads from V11 to V to V44

from Vfrom V44 to V to V66; AVL, and lead I; AVL, and lead I

leads II, III, AVF; and the anterior leads II, III, AVF; and the anterior chest leads chest leads →”reciprocal” →”reciprocal” changes of ST depressionchanges of ST depression

In leads VIn leads V11-V-V44 → reciprocal changes → reciprocal changes

of ST depression and a tall R of ST depression and a tall R wavewave

one or more leads from Vone or more leads from V11 to V to V44

from Vfrom V44 to V to V66; AVL, and lead I; AVL, and lead I

leads II, III, AVF; and the anterior leads II, III, AVF; and the anterior chest leads chest leads →”reciprocal” →”reciprocal” changes of ST depressionchanges of ST depression

In leads VIn leads V11-V-V44 → reciprocal changes → reciprocal changes

of ST depression and a tall R of ST depression and a tall R wavewave

Abnormalities in:Abnormalities in:

Page 74: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Acute full thickness Acute full thickness anterior MIanterior MI

Acute full thickness Acute full thickness anterior MIanterior MI

ST elevation in ST elevation in leads I, AVL, Vleads I, AVL, V22 – –

VV66

Q waves in leads Q waves in leads VV33 – V – V55

ST elevation in ST elevation in leads I, AVL, Vleads I, AVL, V22 – –

VV66

Q waves in leads Q waves in leads VV33 – V – V55

Page 75: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Anterior infarctAnterior infarctwith prominent changes in:with prominent changes in:

Anterior infarctAnterior infarctwith prominent changes in:with prominent changes in:

leads Vleads V22, V, V33, V, V44leads Vleads V22, V, V33, V, V44 leads Vleads V44, V, V55, V, V66leads Vleads V44, V, V55, V, V66

anteroseptal infarct

anteroseptal infarct

anterolateral infarct

anterolateral infarct

Page 76: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Acute full thickness Acute full thickness inferolateral MIinferolateral MI

Acute full thickness Acute full thickness inferolateral MIinferolateral MI

ST elevation in ST elevation in inferior leads II, inferior leads II,

III, AVF III, AVF ST elevation in ST elevation in lateral leads Vlateral leads V44 – V – V66

„„reciprocal” ST reciprocal” ST depression in leads depression in leads

AVL and VAVL and V22

ST elevation in ST elevation in inferior leads II, inferior leads II,

III, AVF III, AVF ST elevation in ST elevation in lateral leads Vlateral leads V44 – V – V66

„„reciprocal” ST reciprocal” ST depression in leads depression in leads

AVL and VAVL and V22

Page 77: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Established full Established full thickness anterior thickness anterior and inferior MIand inferior MI

Established full Established full thickness anterior thickness anterior and inferior MIand inferior MI

Q waves in inferior Q waves in inferior leads II, III, AVF leads II, III, AVF

Q waves with some Q waves with some residual ST residual ST

elevation in the elevation in the anterior leads I and anterior leads I and

VV22 – V – V66

Q waves in inferior Q waves in inferior leads II, III, AVF leads II, III, AVF

Q waves with some Q waves with some residual ST residual ST

elevation in the elevation in the anterior leads I and anterior leads I and

VV22 – V – V66

Page 78: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Plasma enzymesPlasma enzymesPlasma enzymesPlasma enzymesMI causes a detectable rise in the plasma MI causes a detectable rise in the plasma

concentration of enzymes which are concentration of enzymes which are normally concentrated within cardiac normally concentrated within cardiac

cellscells

most widely usedmost widely used →→ ccreatine kinase (CK)reatine kinase (CK) cardiospecific:cardiospecific:

CK-MBCK-MB troponin Ttroponin T troponin Itroponin I

MI causes a detectable rise in the plasma MI causes a detectable rise in the plasma concentration of enzymes which are concentration of enzymes which are

normally concentrated within cardiac normally concentrated within cardiac cellscells

most widely usedmost widely used →→ ccreatine kinase (CK)reatine kinase (CK) cardiospecific:cardiospecific:

CK-MBCK-MB troponin Ttroponin T troponin Itroponin I

Page 79: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Changes in plasma enzyme concentrations Changes in plasma enzyme concentrations after MIafter MI

Changes in plasma enzyme concentrations Changes in plasma enzyme concentrations after MIafter MI

Page 80: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

HEART FAILUREHEART FAILURE

Page 81: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)

A clinical syndrome with many different A clinical syndrome with many different

etiologies that reflects a fundamental etiologies that reflects a fundamental

abnormality in effectiveabnormality in effective mechanical mechanical

performance of the heart, resulting in performance of the heart, resulting in

cardiac output inadequate to meet the cardiac output inadequate to meet the

body’s needs.body’s needs.

A clinical syndrome with many different A clinical syndrome with many different

etiologies that reflects a fundamental etiologies that reflects a fundamental

abnormality in effectiveabnormality in effective mechanical mechanical

performance of the heart, resulting in performance of the heart, resulting in

cardiac output inadequate to meet the cardiac output inadequate to meet the

body’s needs.body’s needs.

Page 82: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)

Impaired cardiac function may be Impaired cardiac function may be

manifested initially only during exertion, manifested initially only during exertion,

but with progression of disease, the but with progression of disease, the

contractile performance of the heart contractile performance of the heart

deteriorates, and symptoms and signs of deteriorates, and symptoms and signs of

congestion and fatigue are associated congestion and fatigue are associated

with a low cardiac output, even at rest..with a low cardiac output, even at rest..

Impaired cardiac function may be Impaired cardiac function may be

manifested initially only during exertion, manifested initially only during exertion,

but with progression of disease, the but with progression of disease, the

contractile performance of the heart contractile performance of the heart

deteriorates, and symptoms and signs of deteriorates, and symptoms and signs of

congestion and fatigue are associated congestion and fatigue are associated

with a low cardiac output, even at rest..with a low cardiac output, even at rest..

Page 83: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)Heart Failure (HF)

In practice, heart failure may be In practice, heart failure may be

diagnosed whenever a patient with diagnosed whenever a patient with

significant heart disease develops the significant heart disease develops the

signs or symptoms of low cardiac signs or symptoms of low cardiac

output, pulmonary congestion or output, pulmonary congestion or

systemic venosus congestion. systemic venosus congestion.

In practice, heart failure may be In practice, heart failure may be

diagnosed whenever a patient with diagnosed whenever a patient with

significant heart disease develops the significant heart disease develops the

signs or symptoms of low cardiac signs or symptoms of low cardiac

output, pulmonary congestion or output, pulmonary congestion or

systemic venosus congestion. systemic venosus congestion.

Page 84: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The cardiac output is a function of:The cardiac output is a function of:

the preloadthe preload

the afterloadthe afterload

myocardial contractilitymyocardial contractility

The cardiac output is a function of:The cardiac output is a function of:

the preloadthe preload

the afterloadthe afterload

myocardial contractilitymyocardial contractility

the volume and pressure of blood in the ventricle at

the end of diastole

the volume and pressure of blood in the ventricle at

the end of diastole

the arterial resistancethe arterial resistance

Page 85: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The renin-angiotensin-aldosterone system in HFThe renin-angiotensin-aldosterone system in HFThe renin-angiotensin-aldosterone system in HFThe renin-angiotensin-aldosterone system in HF

AngiotensinogenAngiotensinogen

Angiotensin IAngiotensin I

Angiotensin IIAngiotensin II

AldosteroneAldosterone

Salt and water

retention

Salt and water

retention

Potassium lossPotassium loss

AfterloadAfterload

PreloadPreload

ContractilityContractility

Direct

vasoconstriction

Direct

vasoconstriction

Activation of sympathetic nervous

system

Activation of sympathetic nervous

system

Release of antidiuretic hormnoe

Release of antidiuretic hormnoe

renin

Angiotensin-converting enzyme

Page 86: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Types of heart failureTypes of heart failureTypes of heart failureTypes of heart failure

Heart failure can be Heart failure can be

described or described or

classified in several classified in several

ways.ways.

Heart failure can be Heart failure can be

described or described or

classified in several classified in several

ways.ways.

Page 87: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Types of heart failureTypes of heart failureTypes of heart failureTypes of heart failure

Acute heart Acute heart

failurefailure

develop suddenly, develop suddenly,

as in myocardial as in myocardial

infarction infarction

Acute heart Acute heart

failurefailure

develop suddenly, develop suddenly,

as in myocardial as in myocardial

infarction infarction

Chronic heart Chronic heart

failurefailure

develop gradually as develop gradually as

in progressive in progressive

valvular heart valvular heart

diseasedisease

Chronic heart Chronic heart

failurefailure

develop gradually as develop gradually as

in progressive in progressive

valvular heart valvular heart

diseasedisease

Page 88: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

When there is gradual impairment of When there is gradual impairment of

cardiac function, a variety of cardiac function, a variety of

compensatory changes may take place.compensatory changes may take place.

Although initially these changes may Although initially these changes may

improve overall cardiac function, as the improve overall cardiac function, as the

disease progresses they often become disease progresses they often become

counterproductivecounterproductive

When there is gradual impairment of When there is gradual impairment of

cardiac function, a variety of cardiac function, a variety of

compensatory changes may take place.compensatory changes may take place.

Although initially these changes may Although initially these changes may

improve overall cardiac function, as the improve overall cardiac function, as the

disease progresses they often become disease progresses they often become

counterproductivecounterproductive

Page 89: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The term compensated heart failure The term compensated heart failure

is sometimes used to describe a is sometimes used to describe a

patient with impaired cardiac patient with impaired cardiac

function in whom adaptive changes function in whom adaptive changes

have prevented the development of have prevented the development of

overt heart failure overt heart failure

The term compensated heart failure The term compensated heart failure

is sometimes used to describe a is sometimes used to describe a

patient with impaired cardiac patient with impaired cardiac

function in whom adaptive changes function in whom adaptive changes

have prevented the development of have prevented the development of

overt heart failure overt heart failure

Page 90: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Compensatory changes in heart failureCompensatory changes in heart failureCompensatory changes in heart failureCompensatory changes in heart failure

Local changesLocal changes Chamber Chamber enlargementenlargement

Myocardial Myocardial hypertrophyhypertrophy

Increased heart rateIncreased heart rate

Local changesLocal changes Chamber Chamber enlargementenlargement

Myocardial Myocardial hypertrophyhypertrophy

Increased heart rateIncreased heart rate

Systemic changesSystemic changes Activation of sympathetic Activation of sympathetic

nervous systemnervous system Activation of the renin-Activation of the renin-

angiotensin-aldosterone angiotensin-aldosterone systemsystem

Release of antidiuretic Release of antidiuretic hormonehormone

Release of natiureic Release of natiureic peptidespeptides

Systemic changesSystemic changes Activation of sympathetic Activation of sympathetic

nervous systemnervous system Activation of the renin-Activation of the renin-

angiotensin-aldosterone angiotensin-aldosterone systemsystem

Release of antidiuretic Release of antidiuretic hormonehormone

Release of natiureic Release of natiureic peptidespeptides

Page 91: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Factors that may precipitate or aggravate Factors that may precipitate or aggravate heart failureheart failure

Factors that may precipitate or aggravate Factors that may precipitate or aggravate heart failureheart failure

Myocardial ischaemia Myocardial ischaemia or infarctionor infarction

Intercurrent illness (e.g. Intercurrent illness (e.g. infection)infection)

ArrhytArrhythhmiamia Inappropriate reduction Inappropriate reduction

of therapyof therapy Pulmonary embolismPulmonary embolism

Intravenous fluid Intravenous fluid overload (e.g. post-overload (e.g. post-

operative i.v. infusion)operative i.v. infusion)

Myocardial ischaemia Myocardial ischaemia or infarctionor infarction

Intercurrent illness (e.g. Intercurrent illness (e.g. infection)infection)

ArrhytArrhythhmiamia Inappropriate reduction Inappropriate reduction

of therapyof therapy Pulmonary embolismPulmonary embolism

Intravenous fluid Intravenous fluid overload (e.g. post-overload (e.g. post-

operative i.v. infusion)operative i.v. infusion)

Administration of drug Administration of drug with negative inotropic with negative inotropic

(e.g. (e.g. ββ-adrenoceptor -adrenoceptor antagonist) or fluid-antagonist) or fluid-

retaining properties (e.g. retaining properties (e.g. non-steroidal anti-non-steroidal anti-

inflammatory drugs, inflammatory drugs, corticosteroids)corticosteroids)

Conditions associated Conditions associated with increased metabolic with increased metabolic demand (e.g. pregnancy, demand (e.g. pregnancy, thyrotoxicosis, anaemia)thyrotoxicosis, anaemia)

Administration of drug Administration of drug with negative inotropic with negative inotropic

(e.g. (e.g. ββ-adrenoceptor -adrenoceptor antagonist) or fluid-antagonist) or fluid-

retaining properties (e.g. retaining properties (e.g. non-steroidal anti-non-steroidal anti-

inflammatory drugs, inflammatory drugs, corticosteroids)corticosteroids)

Conditions associated Conditions associated with increased metabolic with increased metabolic demand (e.g. pregnancy, demand (e.g. pregnancy, thyrotoxicosis, anaemia)thyrotoxicosis, anaemia)

Page 92: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Types of heart failureTypes of heart failureTypes of heart failureTypes of heart failure

Left-sidedLeft-sided heart failure heart failure

Left-sidedLeft-sided heart failure heart failure

Right-sidedRight-sided heart heart

failurefailure

Right-sidedRight-sided heart heart

failurefailure

BiventricularBiventricular heart heart

failurefailure

BiventricularBiventricular heart heart

failurefailure

Page 93: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The left side of heartThe left side of heartThe left side of heartThe left side of heart

Left atriumLeft atrium

Mitral valveMitral valve

Left ventricleLeft ventricle

Aortic valveAortic valve

Left atriumLeft atrium

Mitral valveMitral valve

Left ventricleLeft ventricle

Aortic valveAortic valve

Page 94: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The right side of heartThe right side of heartThe right side of heartThe right side of heart

Right atrium Right atrium

Tricuspid valve Tricuspid valve

Right ventricle Right ventricle

Pulmonary valve Pulmonary valve

Right atrium Right atrium

Tricuspid valve Tricuspid valve

Right ventricle Right ventricle

Pulmonary valve Pulmonary valve

Page 95: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Left-side heart failureLeft-side heart failure

reduction in the left ventricular outputreduction in the left ventricular output

and/orand/or

increase in the left atrial or pulmonary increase in the left atrial or pulmonary

pressurepressure

reduction in the left ventricular outputreduction in the left ventricular output

and/orand/or

increase in the left atrial or pulmonary increase in the left atrial or pulmonary

pressurepressure

Page 96: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Left-side heart failureLeft-side heart failure An acute increase in left atrial pressure may An acute increase in left atrial pressure may

cause pulmonary congestion or pulmonary cause pulmonary congestion or pulmonary

oedemaoedema

A more gradual increase in the left atrial A more gradual increase in the left atrial

pressure may lead to reflex pulmonary pressure may lead to reflex pulmonary

vasoconstriction, which protects the patient vasoconstriction, which protects the patient

from pulmonary oedema at the cost of from pulmonary oedema at the cost of

increasing pulmonary hypertension.increasing pulmonary hypertension.

An acute increase in left atrial pressure may An acute increase in left atrial pressure may

cause pulmonary congestion or pulmonary cause pulmonary congestion or pulmonary

oedemaoedema

A more gradual increase in the left atrial A more gradual increase in the left atrial

pressure may lead to reflex pulmonary pressure may lead to reflex pulmonary

vasoconstriction, which protects the patient vasoconstriction, which protects the patient

from pulmonary oedema at the cost of from pulmonary oedema at the cost of

increasing pulmonary hypertension.increasing pulmonary hypertension.

Page 97: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Right-side heart failureRight-side heart failure

reduction in the right ventricular outputreduction in the right ventricular output

for any given right atrial pressurefor any given right atrial pressure

Causes of isolated right heart failure include Causes of isolated right heart failure include

chronic lung disease (cor pulmonare), multiple chronic lung disease (cor pulmonare), multiple

pulmonary emboli, and pulmonary valvular pulmonary emboli, and pulmonary valvular

stenosisstenosis

reduction in the right ventricular outputreduction in the right ventricular output

for any given right atrial pressurefor any given right atrial pressure

Causes of isolated right heart failure include Causes of isolated right heart failure include

chronic lung disease (cor pulmonare), multiple chronic lung disease (cor pulmonare), multiple

pulmonary emboli, and pulmonary valvular pulmonary emboli, and pulmonary valvular

stenosisstenosis

Page 98: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Biventricular heart failureBiventricular heart failure

It may develop because:It may develop because:

the disease process (e.g. dilated cardiomyopathy the disease process (e.g. dilated cardiomyopathy

or ischemic heart disease) affects both ventriclesor ischemic heart disease) affects both ventricles

oror

disease of the left heart leads to chronic elevation disease of the left heart leads to chronic elevation

of the left atrial pressure, pulmonary of the left atrial pressure, pulmonary

hypertension and subsequent right heart failurehypertension and subsequent right heart failure

It may develop because:It may develop because:

the disease process (e.g. dilated cardiomyopathy the disease process (e.g. dilated cardiomyopathy

or ischemic heart disease) affects both ventriclesor ischemic heart disease) affects both ventricles

oror

disease of the left heart leads to chronic elevation disease of the left heart leads to chronic elevation

of the left atrial pressure, pulmonary of the left atrial pressure, pulmonary

hypertension and subsequent right heart failurehypertension and subsequent right heart failure

Page 99: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Forward and backward heart Forward and backward heart failurefailure

Forward and backward heart Forward and backward heart failurefailure

The predominant The predominant problem:problem:

an inadequate cardiac an inadequate cardiac

outputoutput

Forward heart failureForward heart failure

The predominant The predominant problem:problem:

an inadequate cardiac an inadequate cardiac

outputoutput

Forward heart failureForward heart failure

Normal or near-normal Normal or near-normal cardiac output with cardiac output with

marked salt and water marked salt and water retentionretention

pulmonary and systemic pulmonary and systemic

venosus congestionvenosus congestion

Backward failureBackward failure

Normal or near-normal Normal or near-normal cardiac output with cardiac output with

marked salt and water marked salt and water retentionretention

pulmonary and systemic pulmonary and systemic

venosus congestionvenosus congestion

Backward failureBackward failure

Page 100: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Diastolic and systolic dysfunctionDiastolic and systolic dysfunctionDiastolic and systolic dysfunctionDiastolic and systolic dysfunction

Impaired myocardial Impaired myocardial contractioncontraction

systolic dysfunctionsystolic dysfunction

Impaired myocardial Impaired myocardial contractioncontraction

systolic dysfunctionsystolic dysfunction

Abnormal ventricular Abnormal ventricular relaxationrelaxation

poor ventricular fillingpoor ventricular filling

high filling pressurehigh filling pressure

Diastolic dysfunctionDiastolic dysfunction

Abnormal ventricular Abnormal ventricular relaxationrelaxation

poor ventricular fillingpoor ventricular filling

high filling pressurehigh filling pressure

Diastolic dysfunctionDiastolic dysfunction

Systolic and diastolic dysfunction often coexist, particularly in patients with CAD

Systolic and diastolic dysfunction often coexist, particularly in patients with CAD

Page 101: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

High output failureHigh output failureHigh output failureHigh output failure

Condition that are associated with a very Condition that are associated with a very

high cardiac output high cardiac output

(e.g. large AV shut, beri-beri, severe (e.g. large AV shut, beri-beri, severe

anaemia or thyrotoxicosis) can anaemia or thyrotoxicosis) can

ooccasionally cause heart failure. ccasionally cause heart failure.

In such cases additional causes of heart are In such cases additional causes of heart are

often present.often present.

Condition that are associated with a very Condition that are associated with a very

high cardiac output high cardiac output

(e.g. large AV shut, beri-beri, severe (e.g. large AV shut, beri-beri, severe

anaemia or thyrotoxicosis) can anaemia or thyrotoxicosis) can

ooccasionally cause heart failure. ccasionally cause heart failure.

In such cases additional causes of heart are In such cases additional causes of heart are

often present.often present.

Page 102: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Heart failure – clinical featuresHeart failure – clinical featuresHeart failure – clinical featuresHeart failure – clinical features

The clinical picture depends on the The clinical picture depends on the

nature of underlying heart disease, nature of underlying heart disease,

the type of heart failure that it has the type of heart failure that it has

evoked and neutral and endocrine evoked and neutral and endocrine

changes that have developed.changes that have developed.

The clinical picture depends on the The clinical picture depends on the

nature of underlying heart disease, nature of underlying heart disease,

the type of heart failure that it has the type of heart failure that it has

evoked and neutral and endocrine evoked and neutral and endocrine

changes that have developed.changes that have developed.

Page 103: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Reduced ventricular contractilityReduced ventricular contractilityReduced ventricular contractilityReduced ventricular contractility

Progressive ventricular dilatationProgressive ventricular dilatation

In coronary artery disease „akinetic” or In coronary artery disease „akinetic” or „dyskinetic” segments contract poorly and „dyskinetic” segments contract poorly and

may impede the function of the normal may impede the function of the normal segments by distorting their contraction and segments by distorting their contraction and

relaxation patternsrelaxation patterns

Progressive ventricular dilatationProgressive ventricular dilatation

In coronary artery disease „akinetic” or In coronary artery disease „akinetic” or „dyskinetic” segments contract poorly and „dyskinetic” segments contract poorly and

may impede the function of the normal may impede the function of the normal segments by distorting their contraction and segments by distorting their contraction and

relaxation patternsrelaxation patterns

Causes:

•myocarditis/cardiomyopathy (global dysfunction)

•Myocardial infarction (segmental dysfunction)

Causes:

•myocarditis/cardiomyopathy (global dysfunction)

•Myocardial infarction (segmental dysfunction)

Page 104: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Ventricular outflow obstructionVentricular outflow obstructionVentricular outflow obstructionVentricular outflow obstruction

Initially concentric ventricular hypertrophy Initially concentric ventricular hypertrophy allows the ventricle to maintain a normal allows the ventricle to maintain a normal

output by generating a high systolic pressure. output by generating a high systolic pressure. However, secondary changes in the However, secondary changes in the

myocardium and increasing obstruction myocardium and increasing obstruction eventually lead to failure with ventricular eventually lead to failure with ventricular dilatation and rapid clinical deteriorationdilatation and rapid clinical deterioration..

Initially concentric ventricular hypertrophy Initially concentric ventricular hypertrophy

allows the ventricle to maintain a normal allows the ventricle to maintain a normal output by generating a high systolic pressure. output by generating a high systolic pressure.

However, secondary changes in the However, secondary changes in the myocardium and increasing obstruction myocardium and increasing obstruction

eventually lead to failure with ventricular eventually lead to failure with ventricular dilatation and rapid clinical deteriorationdilatation and rapid clinical deterioration..

Causes:

•Hypertension, aortic stenosis (left heart failure)

•Pulmonary hypertension, pulmonary valve stenosis (right

heart failure)

Causes:

•Hypertension, aortic stenosis (left heart failure)

•Pulmonary hypertension, pulmonary valve stenosis (right

heart failure)

Page 105: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Ventricular inflow obstructionVentricular inflow obstructionVentricular inflow obstructionVentricular inflow obstruction

Small vigorous ventricleSmall vigorous ventricle

Dilated hypertrophied atriumDilated hypertrophied atrium

Atrial fibrillation is common and often causes Atrial fibrillation is common and often causes marked deterioration because ventricular filling marked deterioration because ventricular filling

depends heavily on atrial contraction.depends heavily on atrial contraction.

Small vigorous ventricleSmall vigorous ventricle

Dilated hypertrophied atriumDilated hypertrophied atrium

Atrial fibrillation is common and often causes Atrial fibrillation is common and often causes marked deterioration because ventricular filling marked deterioration because ventricular filling

depends heavily on atrial contraction.depends heavily on atrial contraction.Causes:

•Mitral stenosis; tricuspid stenosis

•Endomyocardial fibrosis

•Constructive pericarditis

Causes:

•Mitral stenosis; tricuspid stenosis

•Endomyocardial fibrosis

•Constructive pericarditis

Page 106: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Ventricular volume overloadVentricular volume overloadVentricular volume overloadVentricular volume overload

Dilatation and hypertrophy allow the ventricle to Dilatation and hypertrophy allow the ventricle to generate a high stroke volume and help to generate a high stroke volume and help to

maintain a normal cardiac output. However, maintain a normal cardiac output. However, secondary changes in the myocardium eventually secondary changes in the myocardium eventually

lead to impaired contractility and worsening lead to impaired contractility and worsening heart failure.heart failure.

Dilatation and hypertrophy allow the ventricle to Dilatation and hypertrophy allow the ventricle to generate a high stroke volume and help to generate a high stroke volume and help to

maintain a normal cardiac output. However, maintain a normal cardiac output. However, secondary changes in the myocardium eventually secondary changes in the myocardium eventually

lead to impaired contractility and worsening lead to impaired contractility and worsening heart failure.heart failure.

Causes:

•Mitral regurgitation (LV) Atrial septal defect (RV)

•Aortic regurgitation

•Ventricular septal defect

Causes:

•Mitral regurgitation (LV) Atrial septal defect (RV)

•Aortic regurgitation

•Ventricular septal defect

Page 107: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical featuresClinical featuresClinical featuresClinical features A low cardiac output causes:A low cardiac output causes:

ffatigueatigue llistlessnessistlessness

ppoor effort toleranceoor effort tolerance The peripheries are coldThe peripheries are cold

Blood pressure is lowBlood pressure is low Poor renal perfusion may lead to oliguria Poor renal perfusion may lead to oliguria

and uraemia.and uraemia.

A low cardiac output causes:A low cardiac output causes: ffatigueatigue

llistlessnessistlessness ppoor effort toleranceoor effort tolerance

The peripheries are coldThe peripheries are cold Blood pressure is lowBlood pressure is low

Poor renal perfusion may lead to oliguria Poor renal perfusion may lead to oliguria and uraemia.and uraemia.

Page 108: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical featuresClinical featuresClinical featuresClinical features Pulmonary oedema due to left Pulmonary oedema due to left

heart failure may present with:heart failure may present with:

breathlessness,breathlessness,

orthopnoea,orthopnoea,

paroxysmal nocturnal paroxysmal nocturnal

dyspnoeadyspnoea

respiratory crepitations over respiratory crepitations over

the lung bases.the lung bases.

Pulmonary oedema due to left Pulmonary oedema due to left

heart failure may present with:heart failure may present with:

breathlessness,breathlessness,

orthopnoea,orthopnoea,

paroxysmal nocturnal paroxysmal nocturnal

dyspnoeadyspnoea

respiratory crepitations over respiratory crepitations over

the lung bases.the lung bases.

Page 109: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

The appearance of the chest radiograph in heart failureThe appearance of the chest radiograph in heart failureThe appearance of the chest radiograph in heart failureThe appearance of the chest radiograph in heart failure„ground glass” appearance of

alveolar oedema

„ground glass” appearance of

alveolar oedema

Prominence of upper lobe blood

vessels

Prominence of upper lobe blood

vessels

„ground glass” appearance of

alveolar oedema

„ground glass” appearance of

alveolar oedema

Pleural effusion (usually bilateral)Pleural effusion

(usually bilateral)

Enlarged cardiac

silhouette

Enlarged cardiac

silhouette

Septal or „Kerley B” lines

Septal or „Kerley B” lines

Page 110: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Chest radiograph Chest radiograph

demonstrating demonstrating

pulmonary oedema in pulmonary oedema in

patient with a prosthetic patient with a prosthetic

mitral valve mitral valve

(bottom arrow).(bottom arrow).

This was due to fracture This was due to fracture

of one of the valve of one of the valve

struts; the disc had struts; the disc had

fallen out of the valve fallen out of the valve

and lodged in the aortic and lodged in the aortic

arch arch

(top arrow)(top arrow)

Chest radiograph Chest radiograph

demonstrating demonstrating

pulmonary oedema in pulmonary oedema in

patient with a prosthetic patient with a prosthetic

mitral valve mitral valve

(bottom arrow).(bottom arrow).

This was due to fracture This was due to fracture

of one of the valve of one of the valve

struts; the disc had struts; the disc had

fallen out of the valve fallen out of the valve

and lodged in the aortic and lodged in the aortic

arch arch

(top arrow)(top arrow)

Page 111: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical featuresClinical featuresClinical featuresClinical features

Right heart failure produces a high jugular Right heart failure produces a high jugular

venous pressure, with hepatic congestion and venous pressure, with hepatic congestion and

dependent peripheral oedema:dependent peripheral oedema:

in ambulant patients in bed-bound patientsin ambulant patients in bed-bound patients

the ankles, the thighs and sacrumthe ankles, the thighs and sacrum

Right heart failure produces a high jugular Right heart failure produces a high jugular

venous pressure, with hepatic congestion and venous pressure, with hepatic congestion and

dependent peripheral oedema:dependent peripheral oedema:

in ambulant patients in bed-bound patientsin ambulant patients in bed-bound patients

the ankles, the thighs and sacrumthe ankles, the thighs and sacrum

Page 112: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical featuresClinical featuresClinical featuresClinical features

Massive acMassive acccumulation of umulation of

fluid may cause ascites fluid may cause ascites

or pleural effusionor pleural effusion..

Massive acMassive acccumulation of umulation of

fluid may cause ascites fluid may cause ascites

or pleural effusionor pleural effusion..

Page 113: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

Clinical featuresClinical featuresClinical featuresClinical features

Chronic heart failure is sometimes associated Chronic heart failure is sometimes associated

with marked weight losswith marked weight loss

(cardiac cachexia)(cardiac cachexia)

ccaused by a combination of anorexia and aused by a combination of anorexia and

impaired absorption due to gastrointestinal impaired absorption due to gastrointestinal

congestion, poor tissue perfusion due to a congestion, poor tissue perfusion due to a

low cardiac output, and skeletal muscle low cardiac output, and skeletal muscle

atrophy due to immobility. atrophy due to immobility.

Chronic heart failure is sometimes associated Chronic heart failure is sometimes associated

with marked weight losswith marked weight loss

(cardiac cachexia)(cardiac cachexia)

ccaused by a combination of anorexia and aused by a combination of anorexia and

impaired absorption due to gastrointestinal impaired absorption due to gastrointestinal

congestion, poor tissue perfusion due to a congestion, poor tissue perfusion due to a

low cardiac output, and skeletal muscle low cardiac output, and skeletal muscle

atrophy due to immobility. atrophy due to immobility.

Page 114: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)

ComplicationsComplications

uraemiauraemia

hypokalaemiahypokalaemia

hyponatraemiahyponatraemia

impaired liver function impaired liver function

thromboembolismthromboembolism

arrhythmiasarrhythmias

uraemiauraemia

hypokalaemiahypokalaemia

hyponatraemiahyponatraemia

impaired liver function impaired liver function

thromboembolismthromboembolism

arrhythmiasarrhythmias

Page 115: MYOCARDIAL ISCHEMIC DISORDERS CORONARY ARTERY DISEASE (CAD)