Angina pectoris

Myocardial infarction

BAHUGUNA ,NIMISHA
IMD- BATCH 3
 Terminology:
 coronary heart disease: refers to the failure of
coronary circulation to supply adequate
circulation to cardiac muscle and surrounding
tissue.
 ischemic heart disease: is a disease
characterized by ischaemia to the heart muscle,
usually due to coronary artery disease.
 Angina pectoris : is severe chest pain due to
ischemia of the heart muscle, generally due to
obstruction or spasm of the coronary arteries.
 Myocardial infarction : is the interruption of
blood supply to part of the heart, causing heart
cells to die.
This is most commonly due to occlusion of a
coronary artery following the rupture of a
vulnerable atherosclerotic plaque. The resulting
ischemia and oxygen shortage, if left untreated
for a sufficient period of time, can cause damage
or death of heart muscle tissue.
 Angina pectoris
Classification :
1 - Stable angina : chest discomfort and associated
symptoms precipitated by some activity with
minimal or non-existent symptoms at rest.
Symptoms typically abate several minutes
following cessation of precipitating activities and
resume when activity resumes
2 - Unstable angina : defined as angina pectoris
that changes or worsens.
 It has at least one of these three features:
 it occurs at rest, usually lasting >10 min;
 it is severe and of new onset
 it occurs with a crescendo pattern.
3 - Microvascular angina : characterized by
angina-like chest pain, but have different causes.
The cause of Microvascular Angina is unknown, but
it appears to be the result of poor function in the
tiny blood vessels of the heart, arms and legs
 Pathophysiology
 Angina results when there is an imbalance
between the heart's oxygen demand and supply.
This imbalance can result from
 an increase in demand (e.g. during exercise)
 without a proportional increase in supply (e.g.
due to obstruction or atherosclerosis of the
coronary arteries)
 Pathophysiology
Stable angina
 Also known as effort angina
 the developing atheroma is protected with a
fibrous cap.
 This cap (atherosclerotic plaque) may rupture in
unstable angina, allowing blood clots to
precipitate and further decrease the lumen of the
coronary vessel
 Pathophysiology
Unstable angina
 unstable angina is the reduction of coronary flow
due to
 transient platelet aggregation on apparently
normal endothelium
 coronary artery spasms or coronary thrombosis.
 The process starts with atherosclerosis, and when
inflamed leads to an active plaque, which
undergoes thrombosis and results in acute ischemia,
which finally results in cell necrosis after calcium
entry
 Major risk factors

 Age (≥ 55 for men, ≥ 65 for women)

 Cigarette smoking
 Diabetes mellitus (DM)
 Family History of premature CVD (men <55 yo, female <65)
 Hypertension
 Kidney disease
 Obesity
 Physical inactivity

Conditions that exacerbate or provoke angina

 Medications
 vasodilators
 excessive thyroid replacement
 vasoconstrictors
 Myocardial infarction
 There are two basic types of acute myocardial
infarction:
 Transmural: associated with atherosclerosis
involving major coronary artery.
 It can be subclassified into anterior, posterior, or
inferior.
 Transmural infarcts extend through the whole
thickness of the heart muscle and are usually a
result of complete occlusion of the area's blood
supply.
 Subendocardial: involving a small area in the
subendocardial wall of the left ventricle,
ventricular septum, or papillary muscles.
 Subendocardial infarcts are thought to be a result
of locally decreased blood supply, possibly from
a narrowing of the coronary arteries. The
subendocardial area is farthest from the heart's
blood supply and is more susceptible to this type
of pathology.
 Pathophysiology
 the disruption of an atherosclerotic plaque in an
epicardial coronary artery, which leads to a
clotting cascade, sometimes resulting in total
occlusion of the artery.
 If impaired blood flow to the heart lasts long
enough, it triggers a process called the ischemic
cascade; the heart cells in the territory of the
occluded coronary artery die (chiefly through
necrosis) and do not grow back
 Risk factors

Risk factors for atherosclerosis are generally risk factors for

myocardial infarction:
 Diabetes - the single most important risk factor for ischaemic
heart disease (IHD)
 Tobacco smoking
 Hypercholesterolemia
 Low HDL
 High Triglycerides
 High blood pressure
 Family history of ischaemic heart disease (IHD)
 Obesity[
 Age: Men acquire an independent risk factor at age 45,
Women acquire an independent risk factor at age 55
 Hyperhomocysteinemia (high homocysteine, a toxic
blood amino acid that is elevated when intakes of
vitamins B2, B6, B12 and folic acid are insufficient)
 Stress (occupations with high stress index are known
to have susceptibility for atherosclerosis)
 Alcohol
 Males are more at risk than females
 Electrocardiography in myocardial
infarction
 The 12 lead ECG is used to classify patients into one
of three groups:
 those with ST segment elevation or new
bundle branch block (suspicious for acute injury and a
possible candidate for acute reperfusion therapy with
thrombolytics or primary PCI/angioplasty),
 those with ST segment depression or T wave
inversion (suspicious for ischemia), and
 those with a so-called non-diagnostic or normal ECG.