Coronary artery disease (CAD)

🠶 is a condition in which plaque builds up inside the coronary arteries.

🠶 Coronary arteries are arteries that supply the heart muscle with oxygen-
rich blood. Plaque is made up of fat, cholesterol, calcium, and other
substance found in the blood. Plaque narrows the arteries and reduces
blood flow to your heart muscle. It also makes it more likely that blood
clots will form in your arteries. Blood clots can partially or completely
block blood flow. When the coronary arteries are narrowed or blocked,
oxygen-rich blood can’t reach the heart muscle. This can cause angina or a
heart attack. Without quick treatment, a heart attack can lead to serious
problems and even death.
🠶 The classic symptom of coronary artery disease (CAD) is
ANGINA—pain caused by loss of oxygen and nutrients to the
myo­cardial tissue because of inadequate coronary blood flow.
🠶 In most but not all patients presenting with angina, CAD
symptoms are caused by significant atherosclerosis.
🠶 Unstable angina is sometimes grouped with MI under the
diagnosis of acute coronary syndrome.
ANGINA PECTORIS
Definition of Angina
🠶 It is usually referred as Acute Chest Pain or Discomfort
Resulting from decreased blood supply to the Heart muscle
i.e. MYOCARDIAL ISCHEMIA which occurs due to
imbalance b/w Oxygen supply and Demand

🠶 Generally due to any obstruction (or) Spasm (or) any

Inflammation in the Coronary Artery that results in
decreased blood supply
 CLINICAL PRESENTATIONS TYPES
🠶 Sub Sternal Chest Pain Radiating to
Arms, Shoulders, Neck and Jaw. 🠶 Angina is Classified into
🠶 Tachycardia Four types
🠶 Shortness Of Breath 1. Stable Angina
🠶 Dizziness 2. Variant Angina
🠶 Fatigue 3. Unstable Angina
🠶 Restlessness 4. Microvascular Angina
STABLE ANGINA Variant Angina Unstable Angina Microvascular Angina

Fixed or Exertional • Prinz Metal Angina • Also known as • Symptom of

Angina & most common Cressendo & Un Coronary
common microvascular
• Occurs even at rest disease

• Develops when your • Occurs due to Spasm • Chest Pain follows an • Occurs due to spasm
Hear works of Coronary Arteries irregular Fashion with in the walls of
harder,such as when Small arterial blood
you Exercise • Blockage or Spasm vessels
• Lasts a Short are the main causes
Time,Perhaps Five
minutes or less

• Disappears sooner if • In some people • Is usually more • Pain or Discomfort

you take rest persistent Increases severe and lasts may be mor severe
the risk of serious about 30 minutes or than other types of
complications such more Angina
as Arrhythmias and
Heart Failure
• Risk Factors

• Non Modifiable Risk Factors

1. AGE : > 50 Years
2. GENDER : Males are at higher risk of developing Angina
3. A Positive Family History

• Modifiable Risk Factors

1. Hypertension
2. Diabetes Mellitus
3. Hyperlipidemia
4. Smoking and Alcohol consumption
5. Obesity
• PATHOPHYSIOLOGY
 • DIAGNOSIS ELECTROCARDIOGRAM (ECG) : This Test records
electrical activity of the heart,which is used to diagnose heart
🠶 ☆ Angina Pectoris Can be diagnosed abnormalities such as Arrhythmias or Myocardial Ischemia
by
ECG Changes Such as ST segment depression or Elevation
and T wave inversion may occur in Unstable Angina but are
• Electrocardiogram (ECG) transcient
• Chest X-ray
Prinzmetal Angina is charecterised by ST segment Elevation
• Blood Test
• Echocardiogram
• Stress Test
• Coronary Angiography
• Cardiac Computerized tomography
(CT SCAN) ST segment
ST segment Elevation
depression
🠶 CHEST X-RAY: This non invasive imaging test helps to confirm other underlying dieseases
Which may ccorrelate with the symptoms of Angina

🠶 CARDIAC STRESS TEST: A Cardiac Stress Test is used to know the heart response to
Physical Exertion in a Controlled Environment
It is usually Performed on Tred mill and helps in diagnosing CAD

🠶 CORONARY ANGIOGRAPHY:
During Coronary Angiography, a
type of dye visible by X- ray machine
is injected into blood vessels of your
heart and rapidly takes series of
Angiograms Which are used to
find Plaque and Thrombus
🠶 Echocardiogram: An Echocardiogram Uses Sound Waves to Produce images of heart,
These images helps to find Angina related problems including whether there are areas
of your heart muscles That have been Damaged by Poor blood supply.

🠶 BLOOD TESTS: The tests can Identify Certain Enzymes such as Troponin That
Leaks into the blood after your heart Suffered severe Angina or heart attack
Blood Tests also Identify elevated LDL and Triglycerides that place you at high
risk of CAD and therefore Angina.

🠶 MAGNETIC RESONANCE IMAGING: It determines whether there is good blood flow

to your heart muscles.This blood flow evaluation done twice using a contrast material
The first time is performed during Exertion and the second time during rest. Performing
The Evaluation both With Stress and rest helps determine if the decreased blood flow
occurs with Exercise.
Management of Angina:
🠶 Non Pharmacological Management:
● Take Heart healthy diet, Improve Physical activity by
moderate Cardiac Aerobics.

● Avoid Fatty and Spicy Foods snd take Poly Unsaturated Fatty
Acids.

● weight should be under Control.

● Avoid Sedentary Lifestyle.

● Medication Adherence is of at most importance.

PHARMACOLOGICAL MANAGEMENT
1. NITRATES
2. BETA BLOCKERS
3. CALCIUM CHANNEL BLOCKERS
4. POTASSIUM CHANNEL OPENERS
5. OTHERS [ Ranolazine]
🠶 NITRATES : Nitrates are Vasodilators.
They dialates blood vessels,Improving Blood Flow and allowing
more oxygen rich blood to reach heart muscles.
Examples:
Nitro glycerin (Short acting)
DOSE: 0.3mg to 0.6mg Sublingually.

Isosorbide Mononitrate (Long Acting)

DOSE: 20mg orally twice a day,7 parts apart.

Isosorbide dinitrate
DOSE : 5 to 20mg orally Two to three times a day.

ADVERSE EFFECTS: Headache Nausea Flushing Dizziness Tachycardia

BETA BLOCKERS: These Agents Blocks Beta receptors to which Adrenaline (or)
Nor Adrenaline binds, there by these drugs antagonise the effects of Adrenaline
i.e They cause decreased contractility and increase Blood Supply.

Beta Blockers has two beneficial

effects in Patients with Angina i.e Slowing the Heart rate during stress and
reducing the force ofContraction.

🠶 EXAMPLES: Metoprolol Initial :50mg orally twice a day

Maintenance: 100 to 400 mg per day

Atenolol Initial: 50 mg orally once a day

Maintenance : 50 to 200 mg per day
🠶 ADVERSE EFFECTS: Cold Hands and feet
Dry mouth,skin or Eyes
Dizziness,Weakness
Drowsiness or Fatigue
CALCIUM CHANNEL BLOCKERS:
Calcium Channel Blockers Inhibit movement of Calcium from the Myocardium and
Vascular smooth muscle. Calcium channel Blockers acting on Vascular Smooth
muscle They reduce contraction of arteries and cause increaseindiameter. By
acting on Myocardium they reduce the force of Contractions ofHeart There by
used inAngina.
ADVERSE
EXAMPLES:
EFFECTS:
DI HYDROPYRIDINES : Edema
AMLODIPINE : DOSE: 5 to 10mg Orally once a day Flushing
Maximum Dose: 10mg per day Drowsiness
Dizziness
NON-DI HYDROPYRIDINES: Low blood supply
VERAPAMIL : DOSE : 120 to 180mg Orally Once a day
Maximum Dose: 540mg per day
POTASSIUM CHANNEL OPENERS:
These drugs opens ATP Activated K+ Channel which Results in Hyperpolarization
And turning the charge of vascular membrane more negative thus
causes VASODILATION.
EXAMPLES:
NICORANDIL:
Only drug in the class Aproved for use in Angina.
DOSE: 5mg Twice a day
Maximum Dose: 40mg per day
ADVERSE EFFECTS: Nausea
Vomiting
Low Blood Pressure
Palpitation
RANOLAZINE :
🠶 Ranolazine is an Anti Anginal Medication
🠶 It works by inhibiting Sodium Current which is coupled with
decreased Ca+2 Entry & Contractility & Facilitates Vasodilation
🠶 Ranolazine is used to treat Chronic Angina.
🠶 Ranolazine is not for Acute Angina.

DOSE: 500mg orally twice a day, increase to 1000mg if needed.

ADVERSE EFFECTS: Bloating or swelling of face
Dizziness
Lightheadness
 LIFESTYLE
🠶 Tell the pt. to lessen smoking
🠶
REMEDIES
Eat a healthy diet with limited amounts of
saturated fat, lots of whole grains, and many
fruits and vegetables.
🠶 Plan a safe exercise plan.
🠶 Plan a weight-loss program
🠶 Take anti-angina medications as prescribed
🠶 Treat/prevent diseases or conditions that can
increase your risk of angina, such as diabetes,
high blood pressure and high blood cholesterol.
Myocardial Infarction (MI)
(heart attack)
 What is MI?
A heart attack is when blood vessels
that supply blood to the heart are
blocked, preventing enough oxygen
from getting to the heart. This causes
the muscle to die.
Causes
• Smoking
• High LDL Cholesterol Levels
• High Blood Pressure
• Diabetes
• Chronic Kidney Disease
Symptoms
Chest pain is a major symptom of heart attack.
You may feel the pain in only one part of your
body, or it may move from your chest to your
arms, shoulder, neck, teeth, jaw, belly area, or
back. The pain can be severe or mild.

• A tight band around the chest

• Something heavy sitting on your chest
• Squeezing or heavy pressure
 Symptoms Continued
Chest pain is due to ischemia (a lack of blood
and hence oxygen supply) to the heart muscle.
Approximately one fourth of all myocardial
infarctions are silent, without chest pain or other
symptoms. These cases can be discovered later
on electrocardiograms. This is called “silent
heart attack”.
 Symptoms Continued
• Anxiety
• Cough
• Fainting
• Light-headedness, dizziness
• Nausea or vomiting
• Palpitations (feeling like your heart
is beating too fast or irregularly)
• Shortness of breath
• Sweating, which may be extreme.
If you experience any of these
symptoms call for help. DO NOT
attempt to drive to ER by your self
as this may be unsafe for others.
Risk Factors
Tobacco Use
Certain components of tobacco and tobacco
combustion gases are known to damage blood
vessel walls. The body's response to this type of
injury elicits the formation of atherosclerosis and
its progression, thereby increasing the risk of MI.
 Risk Factors
Hypertension
High blood pressure has consistently been
associated with an increased risk of MI. This
risk is associated with systolic and diastolic
hypertension. The control of hypertension
with appropriate medication has been shown
to reduce the risk of MI significantly.
 Risk Factors
Diabetes Mellitus
Patients with diabetes have a substantially greater risk of
atherosclerotic vascular disease in the heart as well as in
other vascular beds. Diabetes increases the risk of MI
because it increases the rate of atherosclerotic
progression and adversely affects the lipid profile. This
accelerated form of atherosclerosis occurs regardless of
whether a patient has insulin-dependent or non–insulin-
dependent diabetes.
 Risk Factors
Hyperlipidemia
Elevated levels of total cholesterol, LDL, or
triglycerides are associated with an increased risk of
coronary atherosclerosis and MI. Levels of HDL less
than 40 mg/dl also show an increased risk.
Risk Factors Continued
Family History
A family history of premature coronary
disease increases an individual's risk of
atherosclerosis and MI.
 Diagnosis for MI
Electrocardiogram (ECG)
An electrocardiogram is a recording of the electrical activity of
the heart. Abnormalities in the electrical activity usually occur
with heart attacks and can identify the areas of heart muscle that
are deprived of oxygen and/or areas of muscle that have died.
 Diagnosis of MI
Blood Tests
Cardiac enzymes are proteins that are released into
the blood by dying heart muscles. These cardiac
enzymes are creatine phosphokinase (CPK), and
troponin, and their levels can be measured in blood.
These cardiac enzymes typically are elevated in the
blood several hours after the onset of a heart attack.
MI Medication Treatment
Beta Blockers
These medicines decrease the workload on your
heart. Beta blockers also are used to relieve chest
pain or discomfort and to help prevent additional
heart attacks. Beta blockers also are used to correct
irregular heartbeats.
MI Medication Treatment
ACE Inhibitors
These medicines lower blood pressure and
reduce the strain on your heart. They also
help slow down further weakening of the
heart muscle.
MI Medication Treatment
Anticoagulants
These medicines thin the blood and
prevent clots from forming in your
arteries.
MI Medical Procedures
Angioplasty
During angioplasty, a thin, flexible tube with a
balloon on the end is threaded through a blood vessel
to the blocked coronary artery. Then, the balloon is
inflated to push the plaque against the wall of the
artery. This widens the inside of the artery, restoring
blood flow. Also a small mesh tube called a stent
may be put in the artery to help keep it open. Some
stents are coated with medicines that help prevent
the artery from becoming blocked again.
MI Medical Procedures Treatment
Coronary Artery Bypass Grafting (CABG)
Coronary artery bypass grafting also known as
“cabbage” is a surgery in which arteries or veins
are taken from other areas of your body and sewn
in place to go around the blocked coronary
arteries. This provides a new route for blood flow
to the heart muscle.
 MI Prevention
• Keep your blood pressure, blood sugar, and cholesterol
under control.
• Don't smoke.
• Consider drinking 1 to 2 glasses of wine each day. Moderate
amounts of alcohol may reduce your risk of cardiovascular
problems. However, drinking larger amounts does more
harm than good.
• Eat a low-fat diet rich in fruits and vegetables and low in
animal fat.
MI Prevention
• Eat fish twice a week. Baked or grilled fish is better than fried
fish. Frying can destroy some of the health benefits.
• Exercise daily or several times a week. Walking is a good
form of exercise. Talk to your doctor before starting an
exercise routine.
• Lose weight if you are overweight.
• If you have one or more risk factors for heart disease, talk to
your doctor about possibly taking aspirin to help prevent a
heart attack.
• It’s been shown that aspirin lowers a chance of MI for about
30%.