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Atherosclerosis
VASCULAR BIOLOGY OF ATHEROSCLEROSIS
Evolution of atherosclerotic plaque
Stages of plaque development
Stable vs vulnerable plaques
Clinical sequelae of atherosclerosis
Atherosclerosis timeline
Ischemic Heart Disease
• In 1772, the British physician William Heberden reported a disorder in which
patients developed an uncomfortable sensation in the chest when walking and
disappear soon after the patient stood still but would recur with similar activities
• The clinical presentation of ischemic heart disease can be highly variable and
forms a spectrum of syndromes
Ischemic Syndromes
DETERMINANTS OF MYOCARDIAL OXYGEN SUPPLY AND DEMAND

• In the normal heart, the oxygen

requirements of the myocardium are
continuously matched by the coronary
arterial supply
• Even during vigorous exercise, when the
metabolic needs of the heart increase, so
does the delivery of oxygen to the
myocardial cells so that the balance is
maintained
Stable Angina
Pectoris

Pathophysiology of Heart Disease by Leonard S. Lilly MD

Stable Angina Pectoris

• Manifests as a pattern of predictable, transient chest discomfort during exertion or

emotional stress.
• It is generally caused by fixed obstructive atheromatous plaque in one or more
coronary arteries
• The pattern of symptoms is usually related to the degree of stenosis
 Stable Angina Pectoris
• Retrosternal chest discomfort (pressure, heaviness, squeezing, burning, or choking sensation)
• Pain localized primarily in the epigastrium, back, neck, jaw, or shoulders
• Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for about 1-5
minutes and relieved by rest or nitroglycerin
• Pain intensity that does not change with respiration, cough, or change in position
• Patients should be asked about the frequency of angina, severity of pain, and number pills of
nitroglycerin used during episodes.
 Unstable vs Stable Angina
STABLE
ANGINA
● “EFFORT” angina; dicetus oleh
aktivitas fisik ataupun
mental/emosi
● Hilang dengan istirahat atau nitrat
● Durasi 1-5 menit
UNSTABLE
ANGINA
● “New onset or worsening angina”;
tidak dapat diprediksi
● Tidak hilang saat istirahat
● Rapid onset, crescendo
● Durasi >10 menit (15-20 min)
CLINICAL FEATURES OF CHRONIC STABLE ANGINA

• History
• it would be ideal to interview and examine a patient during an actual episode
of angina
• most patient are asymptomatic during routine clinic examinations
• a careful history probing several features of the discomfort should be elicited.
CLINICAL FEATURES OF CHRONIC STABLE ANGINA

• Quality
• Angina is most often described as a pressure, discomfort, tightness, burning, or heaviness in the
chest
• sensation to “an elephant sitting on my chest”
• anginal discomfort is neither sharp nor stabbing, and it does not vary significantly with inspiration
or movement of the chest wall. It is a steady discomfort that lasts a few minutes, rarely more than
5 to 10 minutes
• differentiate it from sharper and briefer musculoskeletal pains
• the patient may place a clenched fist over his or her sternum, referred to as the Levine sign
CLINICAL FEATURES OF CHRONIC STABLE ANGINA

• Location
• diffuse rather than localized to a single point
• retrosternal area or in the left precordium but may occur anywhere in the chest
back, arms, neck, lower face, or upper abdomen
• radiates to the shoulders and inner aspect of the arms, especially on the left
side.
CLINICAL FEATURES OF CHRONIC STABLE ANGINA

• Accompanying Symptoms
• During the discomfort of an acute anginal attack, generalized sympathetic and
parasympathetic stimulation may result in tachycardia, diaphoresis, and nausea
• Ischemia also results in transient dysfunction of LV systolic contraction and diastolic
relaxation
• Transient fatigue and weakness are also common, particularly in elderly patients
• When such symptoms occur as a consequence of myocardial ischemia but are
unaccompanied by typical chest discomfort, they are referred to as “anginal equivalents”
CLINICAL FEATURES OF CHRONIC STABLE ANGINA

• Precipitants
• angina is precipitated by conditions that increase myocardial oxygen demand
(e.g., increased heart rate, contractility, or wall stress)
• these include physical exertion, anger, and other emotional excitement
• large meal or cold weather
• generally relieved within minutes after the cessation of the activity that
precipitated it and even more quickly (within 3 to 5 minutes) by sublingual
nitroglycerin
CLINICAL FEATURES OF CHRONIC STABLE ANGINA

• Frequency
• the frequency of episodes varies
• important to inquire about reductions in activities of daily living when taking
the history.
Differential Diagnosis
 CLINICAL FEATURES OF CHRONIC STABLE ANGINA
• Physical Examination
• increased heart rate and blood pressure are common because of the augmented sympathetic
response
• myocardial ischemia may lead to papillary muscle dysfunction and therefore mitral regurgitation
• ischemia-induced regional ventricular contractile abnormalities can sometimes be detected as
an abnormal bulging impulse on palpation of the left chest.
• ischemia decreases ventricular compliance, producing a stiffened ventricle and there ore an S4
gallop on physical examination during atrial contraction
• if patient is free of chest discomfort during the examination, there may be no abnormal
cardiac physical findings
• assess for signs of atherosclerotic disease (carotid bruits, femoral artery bruits or diminished
pulses in the lower extremities)
CLINICAL FEATURES OF CHRONIC STABLE ANGINA
 Diagnostic Studies

• Electrocardiogram
• the most useful tools is an electrocardiogram (ECG) obtained during an anginal episode
• ST-segment and T-wave changes can appear
• acute ischemia usually results in transient horizontal or downsloping ST-segment
depressions and T-wave fattening or inversions.
• ST-segment elevations suggesting severe transmural myocardial ischemia
• ECGs obtained during periods free of ischemia are completely normal in approximately
half of patients with stable angina.
• evidence of a previous MI (e.g., pathologic Q waves) also points to the presence of
underlying coronary disease.
Diagnostic Studies
 Diagnostic Studies
Stress Testing
• normal ECGs between episodes of chest discomfort do not rule out underlying ischemic
heart disease.
• provocative exercise or pharmacologic stress tests are valuable diagnostic and prognostic
aids
• Standard Exercise Testing (treadmill, ergocycle)
• Nuclear Imaging Studies
• Exercise Echocardiography
• Pharmacologic Stress Tests
 Diagnostic Studies
Coronary Angiography
• atherosclerotic lesions are visualized radiographically
following the injection of radiopaque contrast material into
the artery
• indication for patients with:
• anginal symptoms do not respond adequately to
pharmacologic therapy
• unstable presentation
• abnormal non invasive testing
Diagnostic Studies
Non-invasive Imaging of coronary arteries → Cardiac CT Angiography (CCTA)
• intravenous contrast
• can visualize stenosis greater than 50%
• sensitivity of 90% and specificity of 65% to 90%
• screening test to detect coronary artery calcification (CAC)
Assessment of pre-test probability & clinical likelihood of coronary artery disease
Assessment Event Risk
Assessment Event Risk
TREATMENT

• The goals of therapy :

• decrease the frequency of anginal attacks,
• prevent acute coronary syndromes
• prolong survival

• Data demonstrate the benefit of smoking cessation, cholesterol, and blood

pressure control in lowering the risk of coronary disease events
• Improvements in other risk actors or CAD → serum glucose in diabetics, obesity
and physical inactivity
Lifestyle Management
Smoking Cessation
Healthy Diet
TREATMENT
• prevention of anginal attacks
• decrease cardiac workload (i.e.,
reduce myocardial oxygen
demand)
• increase myocardial perfusion
TREATMENT
Medical treatment to prevent acute cardiac events:
• Antiplatelet therapy
• aspirin
• platelet P2Y12 ADP receptor antagonists – clopidogrel, ticagrelor
• Lipid-regulating therapy – statin
• Angiotensin-converting enzyme (ACE) inhibitors
TREATMENT
Revascularization -- coronary revascularization is pursued if:
• the patient’s symptoms of angina do not respond adequately to antianginal
drug therapy
• unacceptable side effects of medications occur
• the patient is found to have high-risk coronary disease or which
revascularization is known to improve survival
TREATMENT
• Percutaneous transluminal coronary angioplasty (PTCA)
• CABG surgery
TREATMENT
Strategi Terapi
4. Acute coronary syndromes
(ACS)
PATHOGENESIS OF ACUTE CORONARY SYNDROMES
CLINICAL FEATURES OF ACUTE CORONARY SYNDROMES
CLINICAL FEATURES OF ACUTE CORONARY SYNDROMES
Diagnosis of Acute Coronary Syndromes

The diagnosis is made on the basis of :

(1) the patient’s presenting symptoms,
(2) acute ECG abnormalities, and
(3) detection of specific serum markers of myocardial necrosis (Troponin, CKMB)
EKG PADA SKA
LAB PADA SKA
TATALAKSANA SKA
TATALAKSANA SKA
(Lanjutan)
PRIMARY PERCUTANEOUS CORONARY
INTERVENTION
COMPLICATION OF ACUTE CORONARY SYNDROMES

• Complication
• Recurrent Ischemia
• Arrhythmias
• Myocardial Dysfunction
• Right Ventricular Infarction
• Mechanical Complication
• Pericarditis
• Thromboembolism
TERIMA KASIH
Textbook reading reference:
Pathophysiology of heart disease (Lilly). Leonard S. Lilly. — Sixth edition