Chapter 33 Coronary Artery Disease and Acute Coronary Syndrome Flashcards Preview

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1

Coronary artery disease (CAD) is a type of blood vessel disorder that is included in the general category of atherosclerosis. The term atherosclerosis comes from two Greek words: athere, meaning “fatty mush,” and skleros, meaning “hard.”
1) This combination means that atherosclerosis begins as?
2) Consequently, atherosclerosis is commonly referred to as?
3) Although this disease can occur in any artery in the body, the atheromas (fatty deposits) prefer the?
4) The terms arteriosclerotic heart disease, cardiovascular heart disease, ischemic heart disease, coronary heart disease, and CAD all describe?

1) soft deposits of fat that harden with age.
2) “hardening of the arteries.”
3) coronary arteries.
4) This disease process.

2

Coronary Artery Disease
- Atherosclerosis-
- Inflammation and?
- CRP- c reactive protein

- Atherosclerosis- focal deposits of lipids and cholesterol intimal wall
* Tobacco use
* Hyperlipidemai
* Hypertension
* Diabetes
* Toxins
- Inflammation and endothelial injury
- CRP- c reactive protein
* Marker of inflammation

3

Atherosclerosis is the major cause of CAD. It is characterized by?

lipid deposits within the intima of the artery. Endothelial injury and inflammation play a central role in the development of atherosclerosis.

4

Etiology and Pathophysiology
The endothelium (inner lining of the vessel wall) is normally nonreactive to platelets and leukocytes, as well as coagulation, fibrinolytic, and complement factors. However, the endothelial lining can be injured as a result of?

tobacco use, hyperlipidemia, hypertension, toxins, diabetes, hyperhomocysteinemia, and infection causing a local inflammatory response

5

What can cause chronic endothelial injury (Stage 1)?

- HTN
- Tobacco use
- Hyperlipidemia
- Hyperhomocysteinemia
- Diabetes
- Infections
- Toxins

6

Explain the fatty streak of the endothelial vessel wall (Stage 2)

Lipids accumulate and migrate into smooth muscle cells

7

Explain the fibrous plaque stage of endothelial injury/damage (Stage 3)

- Collagen covers the fatty streak
- Vessel lumen is narrowed
- Blood flow is reduced
- Fissures can develop

8

Explain the complicated lesion (Stage 4)

- Plaque rupture
- Thrombus formation
- Further narrowing or total occlusion of vessel

9

Pathogenesis of atherosclerosis.

A, Damaged endothelium
B, Fatty streak and lipid core formation
C, Fibrous plaque. Raised plaques are visible: some are yellow; others are white
D, Complicated lesion: thrombus is red; collagen is blue. Plaque is complicated by red thrombus deposition

10

C-reactive protein (CRP), a?

- protein produced by the liver
- nonspecific marker of inflammation
- increased in many patients with CAD
- levels rise when there is systemic inflammation.
- Chronic elevations linked with unstable plaques and oxidation of low-density lipoprotein (LDL) cholesterol.

11

Arteries
- Arteries supply blood to?
- Blockage or narrowing creates?
- Right coronary artery
- Left anterior descending
- Circumflex

- Arteries supply blood to myocardium
- Blockage or narrowing creates ischemia or necrosis
- Right coronary artery
* Right ventricle
* Inferior Surface
- Left anterior descending
* Septum
* Anterior left ventricle
- Circumflex
* Lateral Left ventricle
* Posterior surface

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Risks unmodifiable and modifiable

1) Unmodifiable
- Age
- Gender
- Ethnicity
- Family
- Genetics
2) Modifiable
- Serum Lipids, Diabetes
- Blood pressure, Elevated homocysteine
- Smoking, Psychological state
- Obesity, physical activity

13

Nonmodifiable Risk Factors

• Increasing age
• Gender (more common in men than in women until 75 yr of age)
• Ethnicity (more common in white men than in African Americans)
• Genetic predisposition and family history of heart disease

14

Modifiable Risk Factors
Major & Contributing

1) Major
• Serum lipids:
• Total cholesterol >200 mg/dL
• Triglycerides ≥150 mg/dL*
• LDL cholesterol >160 mg/dL
• HDL cholesterol <40 mg/dL in men or <50 mg/dL in women*
• BP ≥140/90 mm Hg*
• Diabetes
• Tobacco use
• Physical inactivity
• Obesity: Waist circumference ≥102 cm (≥40 in) in men and ≥88 cm (≥35 in) in women*
2) Contributing
• Fasting blood glucose ≥100 mg/dL*
• Psychosocial risk factors (e.g., depression, hostility, anger, stress)
• Elevated homocysteine levels

15

The incidence of CAD is highest among middle-aged men.
1) After age 75, the incidence of serious heart events in men and women equalizes, although CAD causes more deaths in?
2) Additionally, CAD is present in African American women at?

1) more deaths in women than men
2) rates higher than those of their white counterparts

16

highest incidence of coronary artery disease (CAD).

White men

17

CAD: African Americans

• African Americans have an early age of onset of CAD.
• Deaths from cardiovascular diseases (e.g., CAD, stroke) are higher for African Americans than for the overall population in the United States.
• African American women have a higher incidence and death rate related to CAD than white women.

18

CAD: Native Americans

• Native Americans die from heart disease earlier than expected. Mortality rates for those under 65 yr old are twice as high as those of other Americans.
• Major modifiable cardiovascular risk factors for Native Americans are tobacco use, hypertension, obesity, and diabetes.

19

CAD: Hispanics

• Hispanics have slightly lower rates of CAD than either non-Hispanic whites or African Americans.
• Hispanics have lower death rates from CAD than non-Hispanic whites.

20

Collateral Circulation.
Normally some arterial anastomoses or connections, called collateral circulation, exist within the coronary circulation.
1) Two factors contribute to the growth and extent of collateral circulation:
2) When plaque blocks the normal flow of blood through a coronary artery and the resulting ischemia is chronic, what happens?
3) When blockages in coronary arteries occur slowly over a long period, there is a greater chance of?
4) However, with rapid-onset CAD (e.g., familial hypercholesterolemia) or coronary spasm, time is inadequate for?

1) factors contribute to the growth and extent of collateral circulation:
- (1) inherited predisposition to develop new blood vessels (angiogenesis)
- (2) presence of chronic ischemia.

2) increased collateral circulation develops.

3) collateral circulation developing, and the heart muscle may still receive an adequate amount of blood and O2

4) collateral development. Consequently, a reduced blood flow results in a more severe ischemia or infarction.

21

CAD: Men
• First heart event for men is more often?
• Men report more typical?
• Men receive more what than women?
• Mortality rates from CAD have?

• Ml than angina.
• signs and symptoms of angina and MI.
• Men receive more evidence-based therapies (e.g., aspirin, statins, diagnostic catheterization, PCI) when acutely ill from CAD (e.g., MI) than women.
• decreased more rapidly for men than women.

22

CAD: Women
• Women experience the onset of heart disease approximately?
• CAD is the leading cause of?
• More women with MI (compared to men with MI) die of?
• Before menopause, women have?

• 10 yr later than men.
• death for women, regardless of race or ethnicity.
• sudden cardiac death before reaching the hospital.
• higher HDL cholesterol levels and lower LDL cholesterol levels than men. After menopause LDL levels increase

23

Acute coronary syndrome: Men
• After age 75, the incidence of MI in men and women?
• Men present more frequently than women with an?
• Men develop greater?
• Men have larger-diameter coronary arteries than women. Vessel diameter is inversely related to?
• Standard screening for risk of sudden cardiac death (e.g., EP studies) is?

• equalizes.
• acute MI as the first manifestation of CAD.
• collateral circulation than women.
• risk of restenosis after interventions.
• more predictive in men.

24

Acute coronary syndrome: Women
• Women are older than men when seen with?
• Women seek medical care later in the?
• First heart event for women is more often?
• Once a woman reaches menopause, her risk for?
• Fewer women than men manifest the?
• Fatigue is often the first symptom of?
• Women experience more “silent”?
• Among those who have an MI, women are more likely to suffer a?
• Women report more disability after?
• Women who have coronary artery bypass graft surgery have a?

• first MI and often have more co-morbidities.
• CAD process and often are more ill on presentation than men.
• unstable angina than MI.
• MI quadruples.
• “classic” signs and symptoms of UA or MI.
• ACS in women.
• MIs compared with men.
• fatal heart event within 1 yr than men.
• a heart event than men.
• higher mortality rate and more complications after surgery than men.

25

Gender Men vs Women

- Men
* 10-15 years earlier than women
* MI vs Angina
* Big ventricle
* Classic symptoms
* Acute MI- first evidence of CAD
* Better collateral circulation
- Women
* More deaths
* Fatigue
* Menopause
* Palpitations
* Often not treated as quickly.
* Symptoms not classic-Silent MI
* Higher mortality with CABG

26

An elevated serum lipid level is one of the four most firmly established risk factors for CAD. The risk of CAD is associated with a serum cholesterol level greater than?
- or a fasting triglyceride level greater than?

- serum cholesterol level greater than 200 mg/dL (5.2 mmol/L)
- fasting triglyceride level greater than 150 mg/dL (3.7 mmol/L)

27

LDL Cholesterol- more cholesterol
What are the levels?

1) <100 Optimal or < 70 for very high risk
2) 100-129 Near optimal/above optimal
3) 130-159 Borderline high
4) 160-189 High
5) 190 Very high

28

Total Cholesterol- Risk for level > 200 mg/dl
What are the levels?

1) <200 Desirable
2) 200-239 Borderline high
3) 240 High

29

HDL Cholesterol- more protein
What are the levels?

1) <40 Low, Women should be > 50
2) 60 High

30

Serum lipids: For lipids to be used and transported by the body, they must become soluble in blood by combining with proteins. Lipids combine with proteins to form lipoproteins. Lipoproteins are vehicles for fat mobilization and transport and vary in composition. Three major lipoproteins are?

high-density lipoproteins (HDLs), LDLs, and very-low-density lipoproteins (VLDLs).