Physiology & Patophysiology of

Ischemic Heart Disease

- MICHAEL TANAKA -

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 Outlines
•Coronary Blood Flow
•Principles of Cardiac Oxygen Supply and Demand
•Heart Rate and Diastolic Filling Time
•Pathophysiology of Stable Angina and Acute Coronary Syndrome
•Complication of Myocardial Infarction

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 Coronary Blood Flow
Anatomy:
• Branch of Aorta
• Right Coronary Artery (RCA)
• Left Coronary Artery:
• Left Main (LM)
• Left Anterior Descending (LAD)
• Left Circumflex (LCx)

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 Coronary Blood Flow
• UNIQUE !
• Location  epicardial layer, located in grooves
• Systolic vs diastolic
• Coronary perfusion  during diastolic phase
• Myocardial contraction  impede coronary flow
• Balance between oxygen supply and demand

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 Supply vs Demand
• Normal  myocardial needs O2  supplied by coronary artery
• Requirements ↑↑ (vigorous exercise)  delivery O2 to myocard ↑↑

Hb

Q=P
R

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 Wall Stress
• Laplace’s relationship :
• Pressure (systolic)
• Radius LV
• Wall thickness

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 Heart Rate
• HR ↑  contraction ↑  ATP ↑  O2 >>
• Slowing HR  beta blocker, Calcium channel blocker non-
dihydropyridine
• Cardiac cycle:
• Systole  remains constant
• Diastole  varies with heart rate

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Coronary Artery Disease

CAD

Acute
Stable Coronary
Syndrome

ST elevation
Unstable Non ST
Myocardial
Angina elevation MI
Infarction

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 Pathophysiology of CAD
ATHEROSCLEROSIS

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 Atherosclerosis

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 Stable CAD
• Stable plaque
• Angina symptoms (+)
• Provoked with exercise
• Relieved with rest
• Depends on :
• degree of stenosis
• vasodilatation

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Acute Coronary Syndrome
• Rupture plaque !

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 Complication of
Myocardial Infarction

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 Initial Management of
Acute Coronary Syndrome

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 Acute Coronary Syndrome

UAP Klinis

STEMI NSTEMI Enzim EKG

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 Clinical Apporach
Angina Typical

• Retrosternal pain
• Provoked by exercise
• Relieved with resting or nitrate

Atypical

• Shortness of breath
• Palpitation
• Epigastric pain
•  elderly, female, DM, obesity, CKD

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 Angina in ACS ?
• Angina at rest, prolong > 20 mins
• First onset angina, CCS II-III
• Crescendo angina
• Angina post MI

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 ECG in ACS
ST elevation ST ST depression
segment

Q wave T wave

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 ECG evolution in STEMI

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 Cardiac enzyme

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 Initial Management in
Emergency Department
MONACO !
• Morphin
• Oxygen
• Nitrates
• Aspirin  160-320 mg chewable
• Clopidogrel  300 mg po OR Ticagrelor 180 mg po

• Anticoagulant:
• UFH
• Low Molecular Weight Heparin
Beware of COMPLICATION !
• Fondaparinux

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 Reperfusion
STEMI
•Primary PCI  stenting
•Fibrinolytic:
• Streptokinase
• Alteplase

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 Summary
•Coronary blood flow  unique, perfusion in diastole
•Ischemic  imbalance supply dan demand
•Atherosclerosis  plaque  rupture
•Stable vs Acute Coronary Syndrome
•ACS:
• Unstable Angina Pectoris
• Non ST elevation Myocardial Infarction
• ST elevation Myocardial Infarction

•Initial Management  MONACO + reperfusion

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 References
• Braunwald’s Heart Disease, A Textbook of Cardiovascular Medicine
• Pathophysiology of Heart Disease, Leonard S. Lilly
• ESC Guidelines for management of ACS inpatients presenting without
persistent ST elevation
• AHA Guidelines for the management of ST elevation Myocardial
Infarction

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Thank You

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