Coronary Atherosclerotic Heart Diseases Affiliated Hospital of Jining Medical College Dept.of Cardiac Care Unit Guoxia Dong dong.0321163.com2*ContentsAtherosclerosisStable Angina PectorisAcute Coronary Syndrome UA and NSTEMI AMI(STEMI) 3*Self-study Variant AnginaCardiac Syndrome XSilent Myocardial Ischemia Myocardial Bridging4*What Is Atherosclerosis?nAtherosclerosis is the descriptive term for thickened and hardened lesions of the medium and large muscular and elastic arteries. 5*What Is Coronary Heart Disease?6*Coronary heart diseaseatherosclerosisCoronary stenosiscoronary spasmMyocardial ischemia, necrosisIschemic heart disease7*8*Atherosclerosis9*Foam cellFatty steakatheromatous plaquerupturedplaquesFibrousplaqueEndothelial damagefirst decadeThird decadeForth decadeAdapted from Stary HC et al. Circulation 1995;92:1355-1374.medium damage *10What damage does atherosclerosis cause?11*Common locationnCoronary Heart DiseasenCarotid Artery DiseasenPeripheral Arterial DiseasenChronic Kidney Disease12*How does atherosclerosis start and progress?13*nElevated levels of cholesterol and triglycerides in the bloodnHigh blood pressurenCigarette smoking14*Biological processes1. Accumulation of intimal cells smooth muscle cells Macrophages T-lymphocytes15*Biological processes2. Proliferated connective tissue matrix collagen elastic fibers proteoglycans 16*Biological processes3.Accumulation of lipid17*Atherosclerosis-HypothesisHypothesis of lipoprotein infiltrationAggregation of platelets and thrombosisClonal theory The response-to-injury hypothesis 18*nHigh blood pressure,bacterium,virus,toxin,ox-LDL,immune factor,vasoactive substance.nPlatelets are activated, adhesion and aggregation of platelets.nLipidoses, growth factor, proliferation of smooth mucle cells, collagen, lipolytic enzyme.Response-to-injury 19*Pathology and pathophysiology Fatty steak Fibrous plaque Complicated lesion20*Initiation of AtherosclerosisFatty steak formation 21*Initiation of Atherosclerosis22*fibrous plaque23*24*25*Thin Cap Vulnerable Plaque Thrombus Unstable “ Active Volcano”Thick Cap Calcified Plaque Flow-limiting Lesion Stable Angina “ Dormant Volcano ”SAPACSpressure or a squeezing pain !26*Unstable and Stable Plaques薄的纤维帽薄的纤维帽炎性细胞炎性细胞 少的平滑少的平滑 肌细胞肌细胞内皮细胞不完整内皮细胞不完整巨噬细胞巨噬细胞较厚的纤维帽较厚的纤维帽没有炎性细胞没有炎性细胞泡沫细胞泡沫细胞完整的内完整的内 皮细胞皮细胞 较多平滑较多平滑 肌细胞肌细胞Libby P. Libby P. CirculationCirculation. 1995;91:2844-2850 1995;91:2844-2850.unstablestable*28AtherosclerosisnClinical stages Absence of symptom or stage of incubationischemianecrosis(target organ )fibrosis 29*clinical manifestationuGeneral manifestationuAortic atherosclerosisuCoronary artery atherosclerosisuCerebral atherosclerosisuRA atherosclerosisuMesenteric atherosclerosisuPeripheral artery atherosclerosis30*Laboratory ExaminationLack of sensitive and specific methods for early diagnosis Dyslipidemia X-ray：DSA show severity of stenosisDoppler ultrasound: blood flow31*Laboratory Examinationradionuclide： detection of ischemia Echocardiogram： CHDECG and stress test: CHD Angiography: the most direct way Intravascular ultrasound, angioscope CT, MRI32*Risk factors n1.Lipid disorders (Dyslipidemia)nIncreased cholesterol :Tc and LDL-c, TG, ApoB,Lp(a)nDecreased cholesterol: HDL-c apoAn2.Hypertension33*Risk factors n3.DM,Metabolic syndrome or insulin resistance syndrome More diffuse lesion CAD equivalent75-80% cause of death in adult DM are vascular diseases: CAD, cerebrovascular disease, or peripheral vascular disease34*7 years incidence of death/non-fatal MI (East West Study)* These patients had no history of myocardial infarction Haffner SM, et al. N Engl J Med. 1998;339:229234.05101520253035404550Events of MI in 7 yearsNo history of MI OMI No history of MI* OMI non-diabetics diabetics n = 1373n = 1059P 40yrs adults ，4/5 fatal myocardial infarction occured in patiens 65 yrs 7. Male gender/ postmenopausal state： male:female = 2：1, men develop CHD 10 -15 yrs earlier than women 8. alcohol 9. Others: diet,homocysteine, hemostatic factors inflammation/infection36*Drug therapyanti-platelet：aspirin, clopidogrel, GPIIb/IIIa inhitibor, Dipyridamole, cilostazolLipid-loweringHMG-CoA reductase inhibitors（statins） 37*Doubts of patients nQuest 1：My blood pressure is only about 100/60 mmHg,Why give me hypotensor lotensin?38*Doubts of patients nQuestion 2：My shape is not fat, lipid is not high, why give me lipid-lowering drugs, made a mistake?39*Doubts of patients nQuestion 3：I have coronary heart disease,then should I do less activities in order to protect the heart?40*Coronary Heart Disease (CHD)*41Clinical TypenSilent myocardial ischemianAngina pectorisnMyocardial infarctionnIschemic cardiomyopathynSudden cardiac death *42Silent Myocardial IschemiaDefined as documented episodes of ischemia not associated with any typical or atypical symptoms that among patients with obstructive coronary a