Coronary Artery Disease leading cause of morbidity & mortality in industrialised nations.

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2 INTRODUCTION Coronary Artery Disease leading cause of morbidity & mortality in industrialised nations. Although decrease in cardiovascular mortality still major cause of morbidity & burden of disease.

3 Coronary Heart Disease (CHD) >58 million American have at least one form of CHD. 50% of all cardiac deaths result from CHD

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5 Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI 1.24 million Admissions per year STEMI.33 million Admissions per year Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115: *Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million UA.

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7 Coronary Heart Disease The major underlying cause is atherosclerosis. Atherosclerosis is a slow, progressive disease which begins in childhood and takes decades to advance

8 Coronary Heart Disease Plaque (the build-up of lipid/cholesterol) in the artery wall forms as a response to injury to the endothelium in the artery wall.

9 Pathology - ACS Steps to Coronary Artery Occlusion The rupture creates inflammatory response including: Platelet adhesion Platelet aggregation Thrombin formation

10 Pathophysiology of ACS Plaque rupture and subsequent formation of thrombus this can be either occlusive or nonocclusive (STEMI, NSTEMI, USA) Vasospasm such as that seen in Prinzmetal s angina, cocaine use (STEMI, NSTEMI, USA) Progression of obstructive coronary atherosclerotic disease (USA)

11 Spectrum of Chronic Coronary Syndrome Risk factors + hypertension Chronic Coronary Syndrome Endothelial dysfunction Atherosclerosis IHD/angina pectoris Myocardial ischemia Coronary thrombosis Myocardial infarction Arrhythmia & loss of muscle Remodeling Ventricular dilation Acute Coronary Syndrome Congestive heart failure End-stage heart disease

12 Pathophysiology of ACS Acute coronary syndromes can also be due to secondary causes Thyrotoxicosis Anemia Tachycardia Hypotension Hypoxemia Arterial inflammation (infection, arteritis)

13 Acute Coronary Syndrome

14 Definitions Acute coronary syndrome is defined as myocardial ischemia due to myocardial infarction (NSTEMI or STEMI) or unstable angina

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16 UNSTABLE ANGINA : Pain occurring at rest duration > 20min, within one week of first visit New onset angina ~ Class 2 severity, onset with last 2 months Worsening of chest pain increase by at least 1 class, increases in frequency, duration Angina becoming resistance to drugs that previously gave good control. ECG normal, ST depression(>0.5mm), T wave changes

17 ACUTE MYOCARDIAL INFARCTION ECC/ACC DEFN : rise and fall in cardiac enzymes with one or more of the following: Ischaemic type chest pain/symptoms ECG changes ST changes, pathological Q waves Coronary artery intervention data Pathological findings of an acute MI

18 NSTEMI : UNSTABLE ANGINA SYMPTOMS/FINDINGS + POSITIVE CARDIAC ENZYMES STEMI : ST ELEVATION ON ECG + SYMPTOMS

19 Diagnosis Patient History Clinical Examination ECG Risk Factors Biochemical Markers (Troponin I)

20 Symptoms of Ischemic Heart Disease Patient history is often diagnostic. Pressure, squeezing, fullness or pain in center of chest that last for several minutes Chest discomfort that spreads to jaw, neck, shoulders or arms Chest discomfort that spreads into the back or between the shoulders Associated symptoms or anginal equivalents (dyspnea, nausea/vomiting, indigestion, diaphoresis, syncope)

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22 Other symptoms include: Dizziness Lightheadedness Nausea Sweating Shortness of breath

23 FACTS: 33% show no chest pain 40% of patients show Atypical chest pain Diabetes Hypertension Heart failure Prior stroke Myocardial infarction (MI)

24 Acute Coronary Syndrome (ACS): In Women According to the Journal of Pain and Symptom Management: women are less likely to describe their discomfort as pain but rather describe it as chest discomfort, with associated shortness of breath, nausea, or loss of appetite.

25 Acute Coronary Syndrome (ACS): In Women As reported in the American Journal of Cardiology: short-term mortality rate is greater in women who have their first non-st elevation myocardial infarction.

26 Elderly, especially those > 75 exhibit other symptoms: Syncope Confusion Stroke Fatigue Note: 60% of MI patients are > 65

27 Acute Coronary Syndrome (ACS): In Elderly According to the American Journal of Geriatric Cardiology: elderly patients lack anginal pain and have more palpitations, syncope, and dyspnea Typically, chest pain presentation decreases with advanced age.

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