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Ischemia
Ischemia
Ischemia
Myocardial Infarction
Pathophysiology of Myocardial
Ischemia
Bio-Med 350
September 2004
Physiology and Pathophysiology of
Coronary Blood Flow / Ischemia
Heart Rate
Contractility
Wall Tension
MVO2 (Myocardial Oxygen Demand)
10
8
MVO2
cc/min 6
/100g
4
2
100 150 200
Heart Rate (BPM)
Contractility
10
Norepinephrine
Control
MVO2
(cc/min 5
/100g)
Determined by:
Oxygen saturation of
the blood
Coronary perfusion pressure
Coronary vascular resistance Hemoglobin content
of the blood
Coronary Blood Flow
Proportional to perfusion pressure / resistance
Diastole
Systole
Endocardium vs Epicardium
Oxygen Adenosine
Acts as Potent vasodilator
vasoconstrictor Prime mediator of
As O2 levels drop coronary vascular
during ischemia: pre- tone
capillary vasodilation Binds to receptors on
and increased vascular smooth
myocardial blood muscle, decreasing
supply calcium entry into cell
Adenosine
0
60 80 100 115 130
Other endothelial-
derived factors
contribute to
autoregulation
Dilators include:
EDRF (NO)
Prostacyclin
Constrictors include:
Endothelin-1
Coronary Flow Reserve
4 Maximum Flow
Coronary 3
Blood
Flow
2
Resting Flow
1
0 25 50 75 100
Epicardial % Diameter Stenosis
Endocardium and Collaterals
Epicardium
Endocardium
Coronary Steal
Vasodilator Rx (Ado)
R2 decreases
A Flow increases to A
Sub-epicardium
B
R3 - no reserve
Sub-endocardium Increased flow across
R1 GRT P1-2
No change in P1
P2
Flow to B is dependant
on P2 and
Prevalence of CAD in Modern
Society
70
60
Age(years)
50
70%
40 <25
% Donors 50% 25-40
30
>40
20
10 25%
0
Fibrous cap
develops when
smooth muscle cells
migrate to intima,
producing a tough
fibrous matrix which
glues cells together
Intra-vascular Ultrasound (IVUS)
Atherosclerotic Plaque
Physiologic Remodeling
Coronary atherosclerosis
Stable Angina - Symptoms
mid-substernal chest pain
squeezing, pressure-like in quality (closed fist =
Levines sign)
builds to a peak and lasts 2-20 minutes
radiation to left arm, neck, jaw or back
associated with shortness of breath, sweating, or
nausea
exacerbated by exertion, cold, meals or stress
relieved by rest, NTG
Symptoms and Signs:
Coronary Ischemia
Stable Angina - Diagnosis
Exercise Treadmill Test
Stable Angina - Diagnosis
Thallium Stress Test
Stable Angina - Treatment
% Stenosis
68% 14% >70
18% 50-70
<50
0.2 1 4
Rx better Placebo better
Low Molecular Weight Heparin
in Acute Coronary Syndromes
Odds Ratios and 95% CI for Composite Endpoint UH / Placebo Rx
( Death, MI, Re-angina or Revasc at 6-14 days ) (%) (%)
0.2 1 4
LMWH Better UH Better
Acute Myocardial Infarction
ST segment
elevation
ST segment
depression
T wave inversion
Q wave formation
Consequences of Ischemia
(Ischemia begets Ischemia)
chest pain
systolic dysfunction (loss of contraction)
decrease cardiac output
decrease coronary perfusion pressure
diastolic dysfunction (loss of relaxation)
higher pressure (PCWP) for any given volume
dyspnea, decrease pO2, decrease O2 delivery
increased wall tension (increased MVO2)
TIMI 2 Flow = contrast reaches the entire distal vessel but either
at a decreased rate of filling or clearing versus
the other coronary arteries (partial perfusion)
7.2 7.4
6 7.0
6.3
4
0
SK + SQ SK + IV Accel. t-PA t-PA + SK
Heparin Heperan
N: 9,796 10,376 10,344 10,327
GUSTO 90 min Patency
40
20
p < 0.001 p < 0.001
0
SK+ SQ SK + IV Accel. t-PA t-PA + SK
Heparin Heparin
N: 295 282 291 297
p = < 0.001 for Accelerated t-PA vs. all other arms
TIMI Flow Grade Versus
Mortality (GUSTO)
Mortality
12 p=0.01
9 9.7
% of 9.9 p=0.05
Patients
6
7.9
3
4.3
0
TIMI 0 TIMI 1 TIMI 2 TIMI 3
N 259 81 342 447
Coronary Steal
Role of Collaterals
Assumptions
Rest Adenosine Collateral resistance
P1 drops with vasodil
Flow Flow P2 bed with no vaso
dilator reserve
P2 collateral P1 P2 collateral P1
Changing Paradigm The Concept
of Physiologic Remodeling