Pathophysiology and ECG Manifestations Of Coronary Heart Disease
Pipin Ardhianto Cardiovascular Department Medical Faculty of Diponegoro University
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
Causes of ACS Atherosclerosis Cause
Non Atherosclerosis Cause
> 95% ACS because of disruption of plaque
Vasculitis syndrome
Platelet agregation
Intracoronary thrombus
Coronary emboli (IE, prosthetic valve) Congenital anomali of coronary artery Coronary trauma or aneurysm Spasm Increased blood viscosity Increased myocardial demand
Hurst, 2011
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“STRESS“ testing only detects THIS
Usually begin in later childhood
Heart attack, Stroke etc
Pathophysiology of Atheroscelrotic (1)
Hurst, 2011
Pathophysiology of Atheroscelrotic (2)
Zubrycki, M. J Physiol Pharmacol. 2014
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
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Stable VS Unstable Plaque
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
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
SUBSTERNAL, NOT TENDER TO PALP.
LATERAL CHEST WALL/TENDER TO PALP.
REPRODUCIBALITY
WITH EXERTION/ACTIVITY
WITH BREATHING/MOVING
AUTONOMIC SYMPTOMS
PRESENT USUALLY
ABSENT
How To Deal With?
Wu Et al. J of Am Physycian. 2009
ECG Manifestation of ACS
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
NSTE-ACS/UAP
STE MI
• 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
• New or presumably new ST elevation, 2 mm in V13 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
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
Atypical ECG Presentation 1. LBBB or Ventricular paced rhythm
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 )
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
CARDIAC CATHETHERIZATOIN
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 : 80 - 320 mg
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
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)
D = DIET and DIABETES • Memilih makanan sehat 1. 2. 3. 4. 5.
mengurangi lemak total hingga < 30 % dari total asupan energi, asam lemak jenuh < 1/3 dari total lemak dan kolesterol < 300 mg per hari mengganti asam lemak jenuh dengan lemak tidak jenuh dari sayuran dan makanan laut meningkatkan asupan buah, sereal dan sayuran mengurangi total asupan kalori bila berat badan perlu diturunkan mengurangi asupan garam dan alkohol bila tekanan darah tinggi
• Glukosa darah
Target kontrol glukosa darah pada diabetes yakni : kadar glukosa darah puasa 91 – 120 mg/dL, post prandial 136 – 160 mg/dL, HbA1C < 7 % dan menghidari hipoglikemia
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
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F = FUN Hindari stress berlebihan, perbanyak aktivitas rekreasi yang menyenangkan
G = Genetic conseling Terutama terhadap pasien dengan keluarga penyakit jantung prematur.
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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 %
0
20
40
60
Patients (%) Framingham Heart Study Murabito et al Circulation 1993; 88: 2548-54 Courtasy of John Deanfield
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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
