Download Atherosclerosis

Atherosclerosis. IHD. Classification
WHO. Angina pectoris. Classification.
Emergency care. Cardiopulmonary
resuscitation.
DEFINITION
IHD - synonims – coronary
disease,
coronary
insufficiency – is severe
chest pain due to ischemia
(a lack of blood and hence
oxygen supply) of the
heart muscle, generally
due to obstruction or
spasm of the coronary
arteries (the heart's blood
vessels).
RISK FACTORS
Smoking
alcohol abuse
high arterial pressure
Dislipidemia
Diabetes mellitus
Obesity
Excessive consumption of animal fats
thrombogenic factors
Lack of physical activity
Ethiology.
 Smoking
 Dyslipidemia
 Arterial hypertension
 Diabetes mellitus
 Obesity
 Dietary factors
 Thrombogenic factors
 Lack of physical activity
 Alcohol abuse
Causes of IHD




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85 % - stenotic
atherosclerosis of coronary
arteries
10 % - spasm of coronary
arteries
5 % - transitory thrombocytes
aggregates
100 % - combination of these
factors
Morbidity in males is 4 times
higher than in females
Pathogenesis
Atherosclerosis
Atherosclerosis
Distributed chronic disease
characterized by specific
lesions of arteries of elastic
and muscular types as
growths in the walls of
connective tissue with lipid
infiltration of the inner
shell. This leads to organ
and total circulatory
disorders.
Complaints
Complaints and clinical manifestations are determined
by the localization of atherosclerotic plaques, their
vulnerability and the degree of occlusion of the
vascular lumen.
Examples of localization of the pathological process:
*in the coronary arteries - coronary heart disease
*in the vessels of the lower extremities atherosclerosis
*vessels of the brain - the cerebral circulation
disorders.
Atherosclerosis is a
pathologic basis of
coronary heart
disease, brain and
peripheral arteries
diseases. These
diseases cause
over 60% mortality
from all diseases in
developed
countries.
Classification
1.Preclinical, hidden period: nervous, vasomotor and metabolic disorders.
2. Period of clinical manifestations
*The first stage (ischemic) - vasoconstriction, leading to disruption of
trophic and dystrophic changes in the relevant organs.
*The second stage (thrombo necrotic) – micro- or macrofocal necroses
with vessel thrombosis without them.
*The third stage (sclerotic or fibrotic) - development of fibrous, cicatricial
changes in the organs with atrophy of the parenchyma.
Atherosclerosis of cerebral
vessels
Functional research methods
1. Electrocardiography using pharmacological and
exercise testing to detect coronary artery disease
2. Echocardiography (left ventricular hypertrophy).
3. Visualizing the walls of arteries and differentiation of
elements of atherosclerotic plaque by MRI.
4. Determination of coronary calcificates using
computed tomography.
Echocardiography
The accumulation of cholesterol in the
vascular wall - atherosclerotic plaque
Laboratory diagnostic
Total cholesterol
LDL cholesterol
HDL Cholesterol
Triglycerides
less than 5 mmol / l
less than 3 mmol / l
higher than 1 mmol / l
less than 2 mmol / l
Treatment
Diet
Changing lifestyles
Statins - drugs for the
correction of lipid metabolism.
Fibrates - prevent the
absorption of lipids in the
intestine.
Clinical forms of IHD
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1. Sudden coronary death or heart arrest (HA)
2. Angina pectoris (AP)
2.1 Stable angina at exertion.
2.1.1 Stable angina at exertion ( functional class should
be determined).
 2.1.2 Stable angina at exertion in angiographically
intact vessels (coronary syndrome X).
 2.2. Angiospastic angina (angina in rest,
spontaneous, variant, Prinzmetals’ angina)
 2.3. Unstable angina.
 2.3.1. Primary angina.
 2.3.2. Progressive angina.
 3. MYOCARDIAL INFARCTION (МI)
 4. CARDIOSCLEROSIS (postinfarctional,
focal and diffuse)
 5. MYOCARDIAL ASCHEMIA WITHOUT PAIN
 6. CARDIAC RRHYTHM DISORDERS (form)
 7. HEART FAILURE (stage, functional class)
Angina pectoris
Angina is attack of
retrosternal pressing
pain
or
chest
dyscomfort
which
occures in physical
load or emotional
strain and is caused
by
myocardial
ischemia.
Provoking factors:
 physical load;
 Emotional strain;
 cold;
 overeating;
 smoking;
Factors which decrease pain:
 Refuse of physical load;
 Nitroglycerin/
 Patient try to stay or lie down in attack.
Stable angina at exertion
Occurs in the same provoking
factors, is often follows with the
same complains and changes on
ECG.
AP functional classes


І FC – attacks occur in a whery high load 1 – 2
times a year. Coronary arteries lumen is narrowed
not more than on 50 %.
ІІ FC – attacks occur in walking on the plane
surface on the diastance more than 500м, in
going more than on 1 floor upstairs 2 – 3 times a
week. Coronary arteries lumen is narrowed not
more than on 75 %.
 ІІІ FC – attacks occur in walking on the plane surface on the
diastance 200 – 300 м, in going 1 floor upstairs.
Postinfarctional angina. Coronary arteries lumen is
narrowed more than on 75%.
 ІV FC – attacks occur in walking on the plane surface on the
diastance less than on 100 м, in rest. Combination of
coronary and myocardial insufficiency. Complete obturation
of coronary arteries.
Clinical pattern
 The major sign of stenocardia is attack-like pain in the
area of heart. It has squeezing, cutting or burning
character with localization behind a breastbone,
irradiates in a left arm (left shoulder-blade, left half of
neck, lower jaw, sometimes – in a right shoulder or
shoulder-blade). Duration of pain of 5-10 min (more
frequently – 2-5 min).
Coronary syndrome X
 This is a stable angina at exertion when small
coronary arteries are affected.
 Clinical pattern is the same as for stable angina but
coronarography does not show obturation of
coronary arteries.
Angiospastic angina
 Caused by spasm of coronal arteries. Arises up
in young persons, mainly at night, in rest,
when tone of vagus nerve prevails. Duration
of attack till 30 min, during this time ECG
shows changes typical for MI (depression of
ST segment) which disappear after stopping
of attack or application of spasmolysants.
Nitrates are uneffective with the purpose of
removal of attacks.
Unstable angina
Acute coronary syndrome
 This is a result of myocardial ischemia caused by
thrombosis of coronaty artery and its complete
occlusion.
 The syndrome includes:
 1. Unstable angina pectoris.
 Non-Q myocardial infarction.
 3. Q- myocardial infarction.
Unstable angina pectoris
 At a stenocardia which arose up first, the
attacks of pain are observed during 28 days
for persons, which did not have clinical signs
of stenocardia before. Usually this is angina at
exertion.
 Progressing angina is the state, at which duration,
intensity and frequency of anginal attacks, grow in a
dynamics, and the usual dose of medications which
take off an attack becomes insufficient, that requires
its permanent increase.
 Characteristic for progressing stenocardia is pressing pain
behind the sternum, which periodically calms down and
grows, is not removed by nitrates, is accompanied with
swweating, dyspnea, arrhythmia, fear of death. The
episodes of attacks of anginal pain become more frequent,
and periods between attacks shorten.
 Every next attack is heavier, than previous. Nitrates
(nitroglycerine, Nitrosorbidum), which removed the attacks
of anginal pain before, are uneffective, although a patient
uses considerably increased their amount.
Associated
manifestations
 Pain can arise up not obviously due to emotional or
physical loading, but also in rest. Sometimes only
narcotic facilities remove him. On a background a
stenocardia there can be an attack of sharp leftventricular insufficiency with dyspnea, dry cough,
bubbling in the chest.
Diagnostics of angina pectoris
functional tests:
 - exposure to cold;
 - test with hyperwentilation;
tests with dynamic physical load:
 а) veloergometry;
 б) tredmile test;
emotional stress-test;
pharmacological tests;
 а) test with dityridamole;
 б) test with isadrine;
 в) test with ergometrine;
transesophageat atrial electrostimulation;
daily ECG-mpnitoring
coronary angiography.
Tests with physical load
Laboratory examinations
 Complete blood count – 1 time a year
 Byochemical blood serum study (lipid spectre,
cholesterol - 1 time a year)
 ЕCG and functional tests – 2-3 times a year in stable
angina depending on functional class.
Resuscitation measures
Treatment
 Healthy life stile. Correction of risk factors,
limitation of carbonhydratess and saturated
fats in diet. Employment. Psychprrophylaxis.
 Medication (nitrates, other antianginal
preparations on a sedate agents) depending
on a functional class and concomitant
diseases. Sanatorium-resort treatment.
Thank you!