Pathophysiology of Coronary Artery Disease (CAD)

From: Dr. A.P.Netraranjn

Cardiac Anatomy
 Coronary Arteries

Coronary blood supply

Arises from the ascending aorta
Empties into the coronary sinus
 Coronary Arteries

Right Coronary Artery

• Acute Marginals
• Posterior Descending
Artery (PDA)
• Posteriolateral Artery (PLA)

Left Coronary Artery

• Left Main
• Left Anterior Descending (LAD)
– Diagonals
– Septals
• Left Circumflex (LCx)
– Obtuse Marginals (OM)
 Coronary Artery Disease (CAD)

An imbalance in the myocardial oxygen supply:

• Impaired blood flow

• Increased oxygen demand
• Decreased supply
 CAD - Etiology

• Subintimal deposition of atheromas in large and medium-sized coronary

arteries (atherosclerosis).

• Less common - Coronary spasm.

• Rare - Coronary artery embolism, dissection, aneurysm (eg, in Kawasaki

disease), and vasculitis (eg, in SLE, syphilis).
 Myocardial Oxygen Supply and Demand

Factors that Impair Myocardial Oxygen Supply

• Atherosclerosis
– Plaque rupture
• Thrombosis
• Embolism
• Spasm

Factors that Increase Myocardial Oxygen Demand

• Physical exertion
• Stress
– Emotional
– Physical
Progression of Atherosclerosis
Progression of Atherosclerosis
Progression of Atherosclerosis

Plaque
Progression of Atherosclerosis

Angina pectoris
 Progression of Atherosclerosis

Plaque rupture reasons: unclear but probably related to

• Plaque morphology,
• Plaque Ca content, and
• Plaque softening due to an
inflammatory process
 Risk Factors

• Hypertension

• Elevated LDL/decreased HDL

• Smoking

• Obesity

• Diabetes

• Physical inactivity

• Advanced age

• Gender (Male >Female)

 CAD – Clinical Presentation

Common non
Cardiac or
Chest Pain cardiac causes of
non cardiac
chest pain

Angina pectoris
Musculoskeletal
Atypical angina Respiratory disease
Acute coronary syndrome Gastrointestinal
Anxiety/Emotional
Other cardiac or vascular
causes: pericarditis, Aortic
dissection, pulmonary embolism

No Chest Pain = Silent Ischemia

 Angina Pectoris - Symptoms

• Angina may be a vague, barely troublesome ache or may rapidly become a severe,
intense precordial crushing sensation. It is rarely described as pain.

• Discomfort is most commonly felt beneath the sternum, although location varies.

• Radiate to:
– left shoulder and down the inside of the left arm, even to the fingers; straight
through to the back;
– into the throat, jaws, and teeth; and,
– occasionally, down the inside of the right arm. It may also be felt in the upper
abdomen.

• The discomfort of angina is never above the ears or below the umbilicus.
 Angina Pectoris

Symptom severity is often classified by the degree of exertion resulting in angina

Canadian Cardiovascular Classification System of (Stable) Angina Pectoris.

Class Activities Triggering Chest Pain

1 Strenuous, rapid, or prolonged exertion
Not usual physical activities (eg, walking, climbing stairs)
2 Walking rapidly
Walking uphill
Climbing stairs rapidly
Walking or climbing stairs after meals
Cold
Wind
Emotional stress

3 Walking, even 1 or 2 blocks at usual pace and on level ground

Climbing stairs, even 1 flight
4 Any physical activity
Sometimes occurring at rest
 Acute Coronary Syndrome

• Acute coronary syndromes result from acute obstruction of a coronary

artery.

• Consequences depend on degree and location of obstruction and range

from
– Unstable angina
– Non-ST-segment elevation MI (NSTEMI)
– ST-segment elevation MI (STEMI)
– Sudden cardiac death.
Myocardial Infarction

Blo c ke d Blo o d S upply

Oc c lude d
Co ro nary
Arte ry

Damag e d
He art Mus c le
 Myocardial Infarction

Stages of myocardial cell death due

to prolonged lack of oxygen
• Ischemia - insufficient oxygen supply
• Inflammation
• Infarction - necrosis
 Myocardial Infarction

Extent of Infarction
• Subendocardial infarct- isolated in the subendocardial layer
• Transmural infarct - involves
the full thickness of a
portion of myocardium
 MI Classification

Classification is based on ECG changes and presence of cardiac markers in blood.

• Non-ST-segment elevation MI (NSTEMI, subendocardial MI) is myocardial

necrosis (evidenced by cardiac markers in blood; troponin I or T and CPK
will be elevated) without acute ST-segment elevation or Q waves.

• ST-segment elevation MI (STEMI, transmural MI) is myocardial necrosis

with ECG changes showing ST-segment elevation that is not quickly
reversed by nitroglycerin or showing new left bundle branch block Q waves
may be present. Both troponin and CPK are elevated .
 Acute Coronary Syndrome - symptoms

Unstable angina

 Similar to angina pectoris except that the pain is

• more intense
• lasts longer
• is precipitated by less exertion
• occurs spontaneously at rest
• is progressive in nature
• or involves any combination of these features.
 Unstable Angina
Unstable angina is classified based on severity and clinical situation

Braunwald Classification of Unstable Angina :

Classification Description Designation

Severity
I New onset of severe angina or increasing† —
angina
No angina during rest
II Angina during rest within past month but not Subacute angina at rest
within preceding 48 h
III Angina during rest within 48 h Acute angina at rest
Clinical situation
A Develops secondary to an extracardiac condition Secondary UA
that worsens myocardial ischemia

B Develops when no contributory extracardiac Primary UA

condition is present
C Develops within 2 wk of acute MI Post-MI UA
 Acute Coronary Syndrome - symptoms

NSTEMI and STEMI

• Usually - deep, substernal, visceral pain described as aching or

pressure, often radiating to the back, jaw, left arm, shoulders, or all
of these areas.

• The pain is similar to angina pectoris but is usually more severe and
long-lasting; more often accompanied by dyspnoea, diaphoresis,
nausea, and vomiting; and relieved little or only temporarily by rest
or nitroglycerin.
 Acute Coronary Syndrome - Investigations

• Serial ECGs

• Stress testing with ECG

• Serial cardiac markers

• Coronary angiography
ECG - Limb leads

• Three electrodes attached to the left arm, the

right arm, and the left leg, respectively.

• The three bipolar limb leads:

– lead I: right arm–left arm
– lead II: right arm–left leg
– lead III: left leg–left arm

• The unipolar leads:

– aVR lead: right arm
– aVL lead: left arm
– aVF lead: left leg
ECG - Chest leads

• Another six electrodes, placed in

standard positions on the chest wall, give
rise to a further six unipolar leads –
• the chest leads (also known as precordial
leads), V1–V6.
ECG
ECG – Normal tracing
 ECG – ST Segment Depression

ECG demonstrating ST-segment depression (I, V3–V6). ST depression is diagnostic of ischemia.

 ECG – ST Segment Elevation

ECG showing ST elevation on inferior leads (II, III, aVF).

Myocardial Infarction
 Exercise Treadmill Test (ETT)

• Myocardial demand is increased by exercise and perfusion to the heart is examined

by use of ECG.

• “Exercise” can be done by use of treadmill or bicycle; or by use of drugs that increase
heart rate e.g., adenosine, dypiridamole, dobutamine.

• Clinical findings suggestive of ischemia:

– BP falls below resting level
– Significant arrhythmias
– Typical chest pain (>5 on 0-10 scale)
– Significant ECG changes.
 Cardiac markers

 Cardiac markers are cardiac enzymes (eg, CPK-MB) and cell contents (eg, troponin I,
troponin T, myoglobin) that are released into the bloodstream after myocardial cell
necrosis.

 The amount of enzyme release depends on the severity of the injury.

 Each enzyme follows a specific pattern of peak levels in blood.

 Cardiac markers

Time Course of Cardiac Biomarkers after M.I.

 Cardiac markers

Biomarker Range of Mean time Time to return Notes

time to initial to Peak to normal
elevation elevation range
(hrs)

High specificity and sensitivity to

CK-MB 3-12 24 hr 48-72 hr
myocardial necrosis

Near absolute specificity to

cTnI 3-12 24 hr 5-10 d
myocardial necrosis

High sensitivity to even

microscopic areas of necrosis
cTnT 3-12 12 hr – 2d 5-14 d Not an index of acute injury
because of prolonged time to
return to normal
 Coronary angiography

This diagnostic method outlines the lumina of the coronary arteries and can be used to
detect or exclude serious coronary obstruction.

However, coronary arteriography provides no information regarding the arterial wall, and
severe atherosclerosis that does not encroaches on the lumen may go undetected.
 Angiography: Right Coronary Artery (LAO)

Filling defect:
Lesion
 CAD - Management

• General Measures

• Drugs

• Revascularization
Approach to acute coronary syndromes (ACS).
 Revascularization

• Revascularization is the restoration of blood supply to ischemic myocardium

in an effort to limit ongoing damage, reduce ventricular irritability, and
improve short-term and long-term outcomes.

• Modes of revascularization include

1. Thrombolysis with fibrinolytic drugs
2. PCI with or without stent placement
3. CABG.
 Percutaneous Coronary Intervention (PCI)

• PTCA, POBA, Angioplasty

• Cutting balloon angioplasty

• Stenting
Bare metal stents
Drug-eluting stents

• Brachytherapy

• Coronary rotablation and atherectomy

 Coronary Artery Bypass Graft (CABG)

CABG is performed for certain groups:

●
Patients with three or more blocked
arteries

●
If the left main artery is narrowed by
50% or more

●
When the disease portion of the
artery is very long
 T hankyou

For any feedback, please contact Dr. Netraranjn at ap_n@in.com