Pathophysiology and ECG Manifestations Of Coronary Heart Disease

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1 Pathophysiology and ECG Manifestations Of Coronary Heart Disease Pipin Ardhianto Cardiovascular Department Medical Faculty of Diponegoro University

2 Definition of Acute Coronary Syndrome A syndrome largely due to coronary atheroclerosis plaque rupture or erosion, which is further subdivided into presentations with and without ST-segment elevation on the ECG. Antman, E M. 2004

3 Causes of ACS Atherosclerosis Cause > 95% ACS because of disruption of plaque Platelet agregation Intracoronary thrombus Non Atherosclerosis Cause Vasculitis syndrome Coronary emboli (IE, prosthetic valve) Congenital anomali of coronary artery Coronary trauma or aneurysm Spasm Increased blood viscosity Increased myocardial demand Hurst, 2011

4 4 STRESS testing only detects THIS Usually begin in later childhood Heart attack, Stroke etc

5 Pathophysiology of Atheroscelrotic (1) Hurst, 2011

6 Pathophysiology of Atheroscelrotic (2) Zubrycki, M. J Physiol Pharmacol. 2014

7 When will the plaque be ruptured? Vulnerable plaque: Plaques with large lipid core Thin fibrous cap covering lipid core High density of macrophage, matrix metalloproteinase and inflammatory cell Holroyd, 2003

8 8 Stable VS Unstable Plaque

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10 APPROACH Identifying those with chest pain suggestive of IHD/ACS. Thorough history required: Character of pain Onset and duration Location and radiation Aggravating and relieving factors Autonomic symptoms

11 CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN (ADAPTED FROM ROSEN S, EMERGENCY MEDICINE) CHARACTERISTIC SUGGESTIVE OF ANGINA LESS SUGGESTIVE OF ANGINA TYPE OF PAIN DULL PRESSURE/CRUSHING PAIN SHARP/STABBING DURATION 2-5 MIN, <20 MIN SECONDSTO HOURS/CONTINUOUS ONSET GRADUAL RAPID LOCATION/CHEST WALL TENDERNESS REPRODUCIBALITY SUBSTERNAL, NOT TENDER TO PALP. WITH EXERTION/ACTIVITY LATERAL CHEST WALL/TENDER TO PALP. WITH BREATHING/MOVING AUTONOMIC SYMPTOMS PRESENT USUALLY ABSENT

12 How To Deal With? Wu Et al. J of Am Physycian. 2009

13 ECG Manifestation of ACS

14 ECG abnormalities of ischemia Diastolic Injury Current Theory Systolic Injury Current Theory Subendocardial ischemia : ST depression (horizontal/downsloping), T wave inversion Transmural ischemia : ST elevation

15 NSTE-ACS/UAP ST depression 0,5 mm in 2 contiguous leads Inverted symetrical T wave 3 mm in 2 or more concomitant leads Suspect UAP if ST segment changes while chest pain & normal while no complaints Normal ECG does not exclude the possibility of NSTE-ACS STE MI New or presumably new ST elevation, 2 mm in V1-3 or 1 mm in other leads Occurs in 2 concomitant leads Pathologic Q wave (0,03 wide, 1 mm deep) in 2 concomitant leads New or presumably new LBBB

16 ECG evolution of Acute STEMI A = Normal B = Acute ST elevation/tall T C = Hours ST elevation R wave, Q wave begins D = Day 1-2 T wave Biphasic Deeper Q wave E = Days later ST normalizes T wave inverted F = Weeks later ST & T normal Q wave persists Pathophysiologic of Heart Disease: Acute Coronary Syndromes, Lilly, 4th ed, 2007

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19 Atypical ECG Presentation 1. LBBB or Ventricular paced rhythm

20 Atypical ECG Presentation 2. Isolated posterior myocardial infarction Infarct in Infero-basal area Often correspondent to LCx territory Isolated ST depression in V1 V3 Use additionl posterior chest lead to confirm posterior infart ( ST elevation > 0.05mm )

21 Atypical ECG Presentation 3. Left Main Coronary Oclusion ST segment elevation in lead avr or V1 St depression in eight or more other leads Accompanied with hemodynamics compromise

22 CARDIAC CATHETHERIZATOIN

23 PREVENSI KARDIOVASKULAR A. ASPIRIN dan ANTI KOAGULAN Aspirin diberikan secara rutin dan terus menerus pada pasien pasca serangan jantung. Bersama dengan nitrat merupakan obat yang penting bagi kegawat daruratan PJK Bertujuan sebagai anti beku darah Dosis : mg

24 B=BLOOD PRESSURE & BODY WEIGHT Target tekanan darah < 140/90 mmhg mengubah pola hidup terapi obat Kelebihan berat badan dan obesitas Kelebihan berat badan ( BMI > 25 kg/m2 ), obesitas ( BMI > 30 kg/m2 ) mengurangi berat badan dengan diet yang benar dan meningkatkan aktivitas fisik Penurunan berat badan menurunkan tekanan darah, kadar kolesterol, glukosa darah Lingkar pinggang : indeks klinis obesitas dan pantauan penurunan BB Lingkar pinggang pria > 94 cm dan wanita > 80 cm merupakan indikasi penurunan BB

25 C= CHOLESTEROL and CIGARETES CESSATION Target kadar total kolesterol < 190 mg/dl dan kolesterol LDL < 100 mg/dl Kadar kolesterol HDL dan trigliserida tidak sebagai target terapi HDL < 40 mg/dl, Trigliserida > 180 mg/dl meningkatkan risiko Mengubah pola hidup terapi obat : HMG Co A reductase inhibitor (statin)

26 D = DIET and DIABETES Memilih makanan sehat 1. mengurangi lemak total hingga < 30 % dari total asupan energi, asam lemak jenuh < 1/3 dari total lemak dan kolesterol < 300 mg per hari 2. mengganti asam lemak jenuh dengan lemak tidak jenuh dari sayuran dan makanan laut 3. meningkatkan asupan buah, sereal dan sayuran 4. mengurangi total asupan kalori bila berat badan perlu diturunkan 5. mengurangi asupan garam dan alkohol bila tekanan darah tinggi Glukosa darah Target kontrol glukosa darah pada diabetes yakni : kadar glukosa darah puasa mg/dl, post prandial mg/dl, HbA1C < 7 % dan menghidari hipoglikemia

27 E. EDUCATION and EXERCISE EDUCATION - Pencegahan Primer sasaran : kelompok resiko tinggi tujuan : mencegah/mengurangi kejadian PJK - Pencegahan Sekunder Sasaran : kelompok pasien PJK Tujuan : mencegah komplikasi - Pencegahan Tersier Sasaran : kelompok pasien PJK dengan komplikasi Tujuan : mencegah mortalitas dan morbiditas EXERCISE Olahraga aerobik minimal 30 menit yang dilakukan minimal 5 x / minggu 27

28 F = FUN Hindari stress berlebihan, perbanyak aktivitas rekreasi yang menyenangkan G = Genetic conseling Terutama terhadap pasien dengan keluarga penyakit jantung prematur. 28

29 Clinical presentation of coronary disease First clinical presentation of coronary artery disease is frequently an acute coronary syndrome. i.e. can be the last Men 62 % Women 46 % Patients (%) Framingham Heart Study Murabito et al Circulation 1993; 88: Courtasy of John Deanfield

30 30 Take Home Messages ACS largely due to atherosclerosis plaque rupture or erosion Atherosclerosis plaque last a lifetime ECG is the mainstay to determine ACS Pay attention to normal ECG but relevant symptom or Atypical ECG changes on admission. Serial ECG may help Prevention is all the core