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coronary heart

disease

DR.LIU LIXIN
 Definition

        

               CHD  is  defined  as  myocardial 


impairment  due  to  an  imbalance  between 
coronary  blood  flow    and    myocardial 
requirements  caused  by  changes  in    the 
coronary circulation 

         
classification
 silent myocardial ischemia
 angina pectoris
 Myocardial infarction
 Ischemic cardiomyopathy
 Sudden death
Presentation Acute Coronary Syndrome

Emergency
Department Non-ST ↑ ST ↑

In-hospital Unstable Non-Q Q Wave


Angina Wave MI MI

Braunwald E et al. J Am Coll Cardiol 2000;36:970–1062.


Stable angina pectoris

 Stable angina pectoris is a syndrome


due to myocardial ischemia caused by
exertion. It is characterized by episodes
of precordial discomfort or pressure.
The symptom lasts for several minutes,
and relieves by rest or sublingual
nitroglycerin. Stable angina pectoris is
resulted from the unbalance of oxygen
demand and supply. It attacks when
oxygen demand exceeds supply.
Symptoms

 Quality of discomfort (chest


pain):Often patients do not perceive
the discomfort as pain. The physician
must ask about pain equivalents such
as strangling, constriction, tightness,
squeezing, pressing, heaviness
expanding sensation, choking in the
throat or indigestion.
 Location of the discomfort: is most
commonly felt beneath the sternum.
Pain may radiate to the left shoulder
and down the inside of the left arm,
even to the fingers.
Symptoms

 Duration of the Discomfort: Stable


angina pectoris lasts only a short time,
usually 3 to 5 minutes if the
precipitating factor is relieved.
 Precipitating factors: The discomfort
tends to occur during, rather than after,
the exertion. Overeating, coldness,
smoking, tachycardia, Constipation and
shock can also evoke the attacks.
Symptoms

 Frequency:Attacks may vary in


frequency from several/day to
occasional episodes separated by
symptom-free intervals of weeks, or
months.
 Conclusion:Analysis of the symptoms
related by the patient, such as the
quality of the discomfort, the location of
the discomfort, the duration of the
discomfort, the precipitating and
relieving factors, would offer strong
diagnostic clues for angina pectoris.
accessory examination
 Resting electrocardiogram
Stress (exercise) ECG
:Treadmill Test
Ambulatory monitoring
(Holter):
 a prolonged monitoring of ECG in
patients engaged in normal daily
activities, it allows to associate the
alterations of ST-T contours with
patients’ symptoms.
Radionuclide cardiac
imaging:
Selective coronary
arteriography:
Diagnosis and Differential
Diagnosis
 typical symptoms brought on by
exertion and relieved within 1-3 minutes
by rest or by sublingual nitroglycerin.
 ischemic ECG changes during a
spontaneous attack or during an
exercise ECG test.
 Coronary arteriography can confirm the
diagnosis of angina pectoris
Treatment
 Treatment of acute attack of
angina pectoris
b. Resting. To cease activities inducing
angina immediately.
c. Nitroglycerin. Nitroglycerin 0.3~0.6
mg (must be fresh) taken sublingually
d. Isosorbide dinitrate. Isosorbide
dinitrate 5~10 mg taken sublingually
acts within 2-5 minutes
Management of
chronic Angina Pectoris
 Avoidance of precipitating factors
 Drug prophylaxis
1.Nitrates:
Isosorbide dinitrate (Isoket) 10mg qid
orally.
Isosorbide mononitrate (Elantan) 20mg
bid orally.
Nitroglycerin ointment applies to the skin
of the chest once daily.
Drug prophylaxis
2.β-Blockers
Propranolol 10mg tid , or metoprolol
25~100mg bid.
3. Calcium channel blockers:
Nifedipine 10mg tid .
Diltiazem 30~60mg tid or qid.
Verapamil 40~80mg tid or qid.
Drug prophylaxis
4.Anti-platelet agents
Aspirin 100mg qd
Ticlopidine 250mg qd or bid
Clopidogrel 75mg qd
5. Lipid-lowering drugs:Statin
agents
Atorvastatin 20mg qn
Coronary Bypass
Surgery and PTCA
Unstable Angina Pectoris
and Non-ST segment
elevation Myocardial
Infarction
etiopathology
 rupture of an atherosclerotic
plague within the coronary artery
and the subsequent formation of a
thrombus over this.
 coronary spasm
From plaque to thrombosis, key
event:
plaque rupture
Essentials of Diagnosis
Unstable angina
1.New onsent angina:
new <2months,frequent
>3times/day
2.Accelerated angina:
more frequent,severe,prolonged
3.Angina on rest:
Symptoms
Non-ST segment elevatin MI
 chest pain : increased in

frequency, duration, or severity;


lasts 30min
 new related characters, such as

sweating, nausea, emesis,


palpitation, or dyspnea.
 Routine rest or sublingual

nitroglycerin can’t relieve


symptoms completely.
Accessory examination
 ECG:
Accessory examination
 Holter
 Coronary arteriography
 Other tests
4. Total creatine kinase (CK) and its
MB isoenzyme (CK-MB)
5. Cardiac-specific troponin (T or I)
levels s
Diagnosis and
Differential Diagnosis
 The diagnosis of UA can be
established according to the
typical symptoms and laboratory
procedures.
Treatment
 General Measures
2. Admission to Hospotial
3. Bed rest
4. Oxygen, electrocardio monitoring
5. sedative
Anti-platelet agents
 Aspirin:75-325mg/d.
 clopidogrel :75mg/d
 GPⅡb/Ⅲa receptor antagonists :
Tirofiban
Anti-coagulation agents
 Heparin: 80 U/kg intravenous
bolus, then constant intravenous
infusion at 18U/kg.h
 LMWH (Low-molecular-weight
Heparins ):
Enoxaparin 1 mg/kg SC q12h
Fraxiparine 5000u SC q12h
anti-myocardial ischemia
 Nitrates :nitroglycerin
,Isoket(Isoscrbide Dinifrate )
 β-Blockers :
 Calcium channel blockers :
PCI and Coronary Bypass
Surgery