Coronary artery disease

Daniel doddy

Normal Heart

SOME FACTS ABOUT HEART DISEASE

In 2002, 696,947 people died of heart disease, this being 29% of the deaths in the U.S It is the leading death for both men and women in the U.S. On average, it is killing a person every 34 seconds in the U.S alone. Worldwide, coronary heart disease kills more than 7 million people each year

NORMAL CORONARY ANATOMY

Coronary Heart Disease (Plaque, Atherosclerosis)

What Is Heart Attack?

Coronary artery becomes blocked - usually by a clot. Blood flow is closed off and a heart attack begins.

If blockage continues, parts of the heart muscle start to die. Heart may stop beating.

CVD and other major causes of death for all males and females (United States: 2007).
450,000 421,918 400,000 391,886

350,000 292,857 270,018

300,000

Deaths

250,000

200,000

150,000 79,827 100,000 66,689 61,235 35,478 21,800 0 A B C D E F A B D F C E 52,832 43,879 35,904

50,000

Males

Females

Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999

Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

Presentation Of CAD
No symptoms Angina Heart attack

Sudden death

Myocardial Infarction or Heart Attack

Symptoms:

Uncomfortable pressure Fullness

Squeezing pain
Pain spreading to the shoulders Neck and arms

Chest discomfort and light

headedness Anxiety / nervousness sweating

Diagnosis
Electrocardiograms Echocardiograms Stress Tests Nuclear Imaging Angiography

American Heart Association

10 Factors That Increase the Risk of Heart Disease and Heart Attack: 1) Tobacco Smoke 2) High Blood Cholesterol 3) High Blood Pressure 4) Physical Inactivity 5) Obesity and Overweight 6) Diabetes Mellitus 7) Stress 8) Alcohol 9) Diet and Nutrition 10) Age

Risk Assessment
Count major risk factors For patients with multiple (2+) risk factors
Perform 10-year risk assessment

For patients with 01 risk factor

10 year risk assessment not required Most patients have 10-year risk <10%

ATP III Assessment of CHD Risk

For persons without known CHD, other forms of atherosclerotic disease, or diabetes: Count the number of risk factors:
Cigarette smoking Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL) Family history of premature CHD
CHD in male first degree relative <55 years CHD in female first degree relative <65 years

Age (men 45 years; women 55 years)

Use Framingham scoring for persons with 2 risk factors* (or with metabolic syndrome) to determine the absolute 10-year CHD risk. (downloadable risk Expert algorithms Evaluation, and Treatment of Panel on Detection, at www.nhlbi.nih.gov)
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 1: Age Years 20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

Assessing CHD Risk in Men

Points -9 -4 0 3 6 8 10 11 12 13 Step 4: Systolic Blood Pressure Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 0 1 1 2 1 2 2 3 Step 6: Adding Up the Points Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 7: CHD Risk Point Total 10-Year Risk Risk <0 <1% 0 1% 1 1% 2 1% 3 1% 4 1% 5 2% 6 2% 7 3% 8 4% 9 5% 10 6% Points at Points Point Total 10-Year 11 12 13 14 15 16 17 8% 10% 12% 16% 20% 25% 30%

Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 7 240-279 9 280 11 Step 3: HDL-Cholesterol HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2

Points at

Points at

Points

Age 40-49 Age 50-59 Age 60-69 Age

0 3 5 6 8

0 2 3 4 5

0 1 1 2 3

0 0 0 1 1

Step 5: Smoking Status at 70-79 Nonsmoker Smoker Points at Points at Age 20-39 0 8 Points at

Age 40-49 Age 50-59 Age 60-69 Age 0 5 0 3 0 1 0 1

Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Assessing CHD Risk in Women

Step 1: Age Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 75-79 16 Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 8 240-279 11 13 Step 280 3: HDL-Cholesterol HDL-C (mg/dL) 60 50-59 40-49 Points -1 0 1 Step 4: Systolic Blood Pressure Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6 Step 6: Adding Up the Points Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 7: CHD Risk Point Total 10-Year Risk Risk <9 <1% 9 1% 10 1% 11 1% 12 1% 13 2% 14 2% 15 3% 16 4% 17 5% 18 6% 19 8% Point Total 10-Year 20 21 22 23 24 25 11% 14% 17% 22% 27% 30%

Points at

Points at

Points

Age 40-49 Age 50-59 Age 60-69 Age 0 3 6 8 10 0 2 4 5 7 0 1 2 3 4 0 1 1 2 2

Step 5: Smoking Status at

Age 40-49 Age 50-59 Age 60-69 Age 70-79 <40 2 Nonsmoker 0 0 0 0 0 Note: Risk estimates were derived from the experience of the Framingham Heart 4 Study, Smoker 9 7 2 1

Points at Points at Age 20-39

Points at

Points at

Points

a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 1: Age
Men
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

Women
Points
-9 -4 0 3 6 8 10 11 12 13

Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

Points
-7 -3 0 3 6 8 10 12 14 16

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 2: Total Cholesterol

Men TC
at (mg/dL) 70-79 <160 160-199 200-239 240-279 280 Points at Age 20-39 0 4 7 9 11 Points at Age 40-49 0 3 5 6 8 Points at Age 50-59 0 2 3 4 5 Points at Points Age 60-69 0 1 1 2 3 Age 0 0 0 1 1

Women
79

TC (mg/dL)
<160 160-199 200-239 240-279 280

Points at Age 20-39

0 4 8 11 13

Points at Age 40-49

0 3 6 8 10

Points at Age 50-59

0 2 4 5 7

Points at Points at Age 60-69 Age 700 1 2 3 4 0 1 1 2 2

Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 3: HDL-Cholesterol
Men
HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2

Women
HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2

Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 4: Systolic Blood Pressure

Men
Systolic BP Points (mm Hg) if Untreated <120 0 120-129 0 130-139 1 140-159 1 160 2 Points if Treated 0 1 2 2 3

Women
Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6

Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Men
at 70-79 Nonsmoker Smoker8

Step 5: Smoking Status

Points at Points at Points at Age 50-59 0 1 Points at Age 50-59 0 2 Points at Points Age 60-69 0 1 Age 0 Age 20-39 Age 40-49 0 5 Points at 0 3 Points at

Women
at 70-79 Nonsmoker Smoker9 Points at Points Age 60-69 0 1 Age 0 Age 20-39 Age 40-49 0 7 0 4

Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 6: Adding Up the Points (Sum From Steps 15)

Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 7: CHD Risk for Men

Point Total Risk <0 0 1 2 3 4 5 6 7 8 9 10 10-Year Risk <1% 1% 1% 1% 1% 1% 2% 2% 3% 4% 5% 6% Point Total 11 12 13 14 15 16 17 10-Year 8% 10% 12% 16% 20% 25% 30%

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

ATP III Framingham Risk Scoring

Step 7: CHD Risk for Women

Point Total Risk <9 9 10 11 12 13 14 15 16 17 18 19 10-Year Risk <1% 1% 1% 1% 1% 2% 2% 3% 4% 5% 6% 8% Point Total 20 21 22 23 24 25 10-Year 11% 14% 17% 22% 27% 30%

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

2001, Professional Postgraduate Services www.lipidhealth.org

Key ways to help prevent heart disease:

Dont smoke or use tobacco products
Tobacco smoke contains more than 4,800 chemicals; many of which can damage your heart and blood vessels

Get active
Exercise Gardening Taking the stairs

Eat a heart-healthy diet

Research shows that fruits, vegetables, whole grains and low-fat dairy products that can help protect your heart

Key ways to help prevent heart disease:

Maintain a healthy weight
excess weight can lead to conditions that increase your chances of heart

Get regular health screenings

Blood Pressure Cholesterol Levels

Stress-free
Relax Smile

The Journal of Thoracic and Cardiovascular Surgery May 2009

PCI Procedural refinements: Stents

Expandable metal mesh tubes that buttresses the dilated segment, limit restenosis. Drug eluting stents: further reduce cellular proliferation in response to the injury of dilatation.

Coronary Artery Bypass Grafting (CABG)

CABG
Procedural refinements: arterial rather than vein grafts avoid the cardiopulmonary bypass machine