Coronary Heart Disease

(CHD)

Peter N. Landless, M.B.,B.Ch., M.Med.,

FCP (SA), FACC
 Coronary Heart Disease

 Leading cause of death

in western countries
 Subject of much
research
 Media reports new risk
factors, treatments and
tests – often in the
news

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 Narrowing of the arteries

 Narrowing of the
arteries of the heart
results in:
 Chest Pain (angina)
 Heart attack (myocardial
infarction)
 Heart failure
 Arrhythmias
 Sudden death

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 Structure and function
of the heart
 Muscular organ with
four chambers
 Each heartbeat involves
a muscular contraction
 Blood is sent to the
body via the circulatory
system (arteries)
 Blood returns to the
heart via the veins

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 Structure and function (continued)

 Blood is pumped to the

lungs
 Oxygen is collected and
carbon dioxide released
 A new cycle begins
carrying oxygen to the
tissues

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 Structure and function (continued)

 The heart muscle

requires a supply of
oxygen-rich blood
 This is supplied by the
coronary arteries

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 Structure and function (continued)

 The three main coronary

arteries lie on the
surface of the heart
 These arteries divide
into smaller blood
vessels to feed the
entire heart muscle

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General Conference Health Ministries Charters – Coronary Heart Disease
 Atherosclerosis

 The major underlying

cause of coronary artery
disease is
atherosclerosis
 Narrowing of the
coronary arteries by
deposits called plaques

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 Atherosclerosis (continued)

 Plaques are composed

of:
 Cholesterol-laden
foam cells
 Smooth muscle cells
 Fibrous proteins
 Calcium

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 Atherosclerosis (continued)

 Accumulation of
cholesterol in the cell
wall initiates the
process; it plays a
continuing role in
progression
 Progressive narrowing
with associated clotting
leads to angina or heart
attack

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 Atherosclerosis (Continued)

 This results in muscle

damage/death
 Heart failure and/or
death may follow

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 Fats in the blood

 Cholesterol
 Triglycerides
 Low density lipoprotein
(LDL) Cholesterol
 High-density lipoprotein
(HDL) Cholesterol
 Very low-density
lipoprotein (VLDL)

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 Fats in the blood (Continued)

 LDL/HDL transport
cholesterol
 VLDL is the major
carrier of triglycerides
 HDL can be protective
by transporting
cholesterol from the
arterial deposits to the
liver

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 Plaque rupture (break)

 Various triggers may

result in plaque rupture
 Platelets accumulate
 Clot forms and blocks
the artery
 Muscle damage/death
ensues

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 Symptoms of
coronary heart disease
 Shortness of breath
 Angina (central crushing
chest pain)
 Associated
nausea/sweating
 Dizziness
 Fainting may occur

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 Symptoms (Continued)

 Pain may radiate (move to

places other than chest) or
be atypical:
 Jaw
 Teeth
 Left arm
 Right arm (less frequent)
 There may be no pain –
silent ischemia

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 If any of these symptoms is
noted, seek immediate help

Window of opportunity
is 4-6 hours

Time is Muscle

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 Major Risk Factors
for coronary heart disease (CHD):
 Cigarette smoking
 High blood pressure
 Abnormal blood lipids
(fats)
 Diabetes mellitus
 Family history
 Older age

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 Risk Factors

 Can be divided into two

categories:
 Those that cannot be
changed
 Those that can
 The more risk factors
present, the greater the
chance of developing
CHD

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 Unchangeable risk factors

 Age
 Men over 45 years
 Women over 55
years

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 Unchangeable risk factors
(continued)

 Gender
 CHD more common
in young men than in
young women
 After menopause,
female risk increases
to that of men

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 Unchangeable risk factors

 Heredity
 Male less than 45 years
 Female less than 55
 Diabetes
 Elevated triglycerides
 Low HDL cholesterol
 Hypertension
 Elimination of pre-
menopausal protection
in women

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 Unchangeable risk factors

 Diabetes (continued)
 Aggressive
management of risk
factors is required in
diabetes as well as
excellent sugar
control

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 Unchangeable risk factors
(continued)

 Post-menopausal status
in women:
 Combination estrogen
and progesterone
hormone replacement
therapy does not lower
risk of heart attack and
stroke (JAMA, vol. 288,
p. 321, July 17, 2002)

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 Unchangeable risk factors

 Calcification of aortic
valve (aortic sclerosis)
 Blood clotting
abnormalities
 Homocysteine-probable
marker of vascular
disease

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 Changeable risk factors

 Cigarette smoking
 Hypertension
 Abnormal lipids:
 Elevated cholesterol
 Low HDL cholesterol
 High LDL cholesterol
 High triglycerides

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 Changeable risk factors

 Obesity
 Metabolic syndrome:
 Abnormal obesity
 High triglycerides
 Low HDL cholesterol
 High blood pressure
 Impaired glucose
tolerance

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 Changeable risk factors

 Physical inactivity
 Stress
 C-reactive protein (CRP)
 An elevated CRP predicts
heart attack and
strokes-it is a marker
that indicates increased
risk

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 Diagnosis

 History
 Electrocardiogram
 Exercise stress test
 Nuclear medicine stress
test

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 Diagnosis (Continued)

 Stress echocardiography
 Electron beam
computed tomography
(calcium score)
 Coronary angiography
 Blood markers
(enzymes, troponin,
myogloin)

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 Lifestyle measures
to prevent and treat CHD
 Smoking cessation
 Reduction of dietary fat
(25-30 percent of daily
calories)
 Reduce salt intake (no-
added-salt diet)

J Am Coll Cardio/ 2004; 44;671-719

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 Lifestyle measures to prevent
and treat CHD (Continued)
 Physical activity
 Weight control
 Stress reduction
 Treat homocysteine
(folic acid)

J Am Coll Cardio/ 2004; 44;671-719

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 Alcohol

 There is evidence that

alcohol may have
positive effects on CHD1

Wallerath T et al, JACE 2003

1

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 Negative effects of alcohol

 However, there are

many serious negative
effects of alcohol,
including:
 Addiction
 Heart disease
 Diabetes
 Drunken driving

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 Alcohol (continue)

Negative effects:
 Cancer
 Liver cirrhosis
 Neurologic degeneration
 Violence

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 The evidence is clear2

 Alcohol should not be

prescribed as a preventive
measure for CHD
 People who do not drink
should not consider starting
 Controlling other risk factors
for CHD has a greater
impact on reducing heart
attack, including diet,
exercise, and aspirin
2Diet, Nutrition, and the Prevention of Chronic
Diseases, WHO, 2003, page 90

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 Treatment of CHD

1. Lifestyle modification
2. Treatment risk factors
3. Aspirin
 Primary
 Secondary
4. Lipid lowering drugs
 Primary
 Secondary

J AM Coll Cardiol 2004; 44: 671-719

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 Acute Treatment

 Urgent hospitalization
 Clot “busters” to
dissolve the clot
 Angioplasty – best
choice when available
 Coronary care units

J AM Coll Cardiol 2004; 44: 671-719

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 Short- and long-term treatments

 Cardiac rehabilitation
(exercise; psychological
recovery)
 Lipid control (statins)
 Aspirin
 Beta blockers

J AM Coll Cardiol 2004; 44: 671-719

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 Short- and long-term
treatments (continued)
 Ace-inhibitors
 Risk modification
 Angioplasty where
needed
 Coronary artery bypass
surgery where needed

J AM Coll Cardiol 2004; 44: 671-719

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 Despite innovation of
diagnosis and therapy

Prevention
remains
The cure!!

General Conference Health Ministries Charters – Coronary Heart Disease