3. Intraluminal thrombus
Growth of thrombus
Intraplaque thrombus Lipid pool
Blood Flow
Atherosclerotic Plaque Rupture and
Thrombus Formation
Adapted from Weissberg PL. Eur Heart J Supplements
1999:1:T13–18
4. (Adapted from Glagov et al.)
Coronary Remodeling
Normal
vessel
Minimal
CAD
Progression
Compensatory expansion
maintains constant lumen
Expansion
overcome:
lumen narrows
Severe
CAD
Moderate
CAD
Glagov et al, N Engl J Med, 1987.
5. Clinical Manifestations
of Atherosclerosis
• Coronary heart disease
– Stable angina, acute myocardial infarction, sudden
death, unstable angina
• Cerebrovascular disease
– Stroke, TIAs
• Peripheral arterial disease
– Intermittent claudication, increased risk of death
from heart attack and stroke
American Heart Association, 2000.
6. Definitions
• CARDIOVASCULAR DISEASE or CVD
includes CORONARY ARTERY DISEASE
and other cardiac conditions (congenital,
arrhythmias, and congestive heart failure)
• CORONARY ARTERY DISEASE (CAD) or
CORONARY HEART DISEASE (CHD)
(often broadly referred to as ISCHEMIC
HEART DISEASE (IHD): primarily
myocardial infarction and sudden
coronary death, broader definition may
include angina pectoris, atherosclerosis,
positive angiogram, revascularization, and
myocardial infarction
7. Definitions (cont.)
• REVASCULARIZATION includes coronary
artery bypass graft (CABG), percutaneous
transluminal coronary angioplasty (PTCA),
stent, and atherectomy
• CEREBROVASCULAR DISEASE includes
stroke (ischemic or hemorrhagic) and
transient ischemic attack (TIA)
• PERIPHERAL VASCULAR DISEASE
includes carotid artery disease and
intermittent claudication
• SURROGATE MEASURES include: carotid
intimal medial thickness (IMT), coronary
calcium, angiographic stenosis, brachial
ultrasound flow mediated dilatation (FMD)
8. Approaches to Primary and
Secondary Prevention of
CVD
• Primary prevention involves prevention
of onset of disease in persons without
symptoms.
• Primordial prevention involves the
prevention of risk factors causative o
the disease, thereby reducing the
likelihood of development of the
disease.
• Secondary prevention refers to the
prevention of death or recurrence of
disease in those who are already
symptomatic
9. Risk Factor Concepts in
Primary Prevention
• Nonmodifiable risk factors include age,
sex, race, and family history of CVD,
which can identify high-risk populations
• Behavioral risk factors include sedentary
lifestyle, unhealthful diet, heavy alcohol
or cigarette consumption.
• Physiological risk factors include
hypertension, obesity, lipid problems,
and diabetes, which may be a
consequence of behavioral risk factors.
10. Population vs. High-Risk
Approach
• Risk factors, such as cholesterol or blood
pressure, have a wide bell-shaped distribution,
often with a “tail” of high values.
• The “high-risk approach” involves
identification and intensive treatment of those
at the high end of the “tail”, often at greatest
risk of CVD, reducing levels to “normal”.
• But most cases of CVD do not occur among the
highest levels of a given risk factor, and in fact,
occur among those in the “average” risk group.
• Significant reduction in the population burden
of CVD can occur only from a “population
approach” shifting the entire population
distribution to lower levels.
11. Materials Developed for
Community Intervention
Trials
• Mass media, brochures and direct mail
• Events and contests
• Screenings
• Group and direct education
• School programs and worksite
interventions
• Physician and medical setting programs
• Grocery store and restaurant projects
• Church interventions
• Policies
12. Individual and High-Risk
Approaches
• Primary Prevention Guidelines (1995) and
Secondary Prevention Guidelines (Revised 2001)
released by the American Heart Association
provide advice regarding risk factor assessment,
lifestyle modification, and pharmacologic
interventions for specific risk factors
• Barriers exist in the community and healthcare
setting that prevent efficient risk reduction
• Surveys of CVD prevention-related services show
disappointing results regarding cholesterol-
lowering therapy, smoking cessation, and other
measures of risk reduction
13. CAD
• Leading cause of death in people
over the age of 40
• Almost always due to atheroma and
its complication
14. Pathological condition of CAD
• Stable angina
• Unstable angina
• MI
• Heart failure
• Arrhythmia
• Sudden death
15. Angina pectoris
• Typical manifestation of
symptomatic CAD
• Chest pain due to transient
myocardial ischaemia
• Imbalance between myocardial
oxygen demand
16. Classification of angina
• Stable/ typical/ exertional/ classical
angina- induce by effort and relived
by res
• Unstable/ descendo angina- angina
at rest or rapidly worsening
• Post- infarction angina
• Prinzmetal’s/ Vasospastic/ variant
angina- occurs at rest as a result of
coronary artery spasm
• Nocturnal angina- occurs at night
due to ostial stenosis
17. Character of pain in angina
• Site- retrosternal
• Radiation- neck, jaw, left shoulder,
medial aspect of upper limb
• Character- pressing, squezing, a
band across the chest
• Duration- 1- 3 minutes, never less
than 30 seconds, > 15 mins
18. Character of pain
• Aggravating factors
– Exertion
– Emotion
– Cold
– Heavy meal
– Sexual activity
• Relieving factors
– Rest nitrates
• SoB
19. Investigation
• CBC
• Chest X- ray PA view
• Serum cholesterol and Lipid profile
• ECG
• Coronary angiography – site, extent
and nature
• Echocardiography
21. Drug used
• Nitrates – sublingual nitrates
(0.5mg)
– Oral nitrates – Isosorbide dinitrate 5-
10 mg (4 to 6 hr) Isosorbide monitrate
10 to 20 mg (8 -12 hr)
– Nirtoglycerine injection
• Calcium channel blocker –
Nifedipine
• Beta Blocker
• Aspirin and clopidegrol
22. ACS
• Describe a range of thrombotic
coronary disease from unstable
angina to acute MI
23. Treatment of unstable angina
• Bed rest
• Admit in CCU
• ECG monitoring
• High flow oxygen
• Correction of precipitating factor
HTN, DM etc
• Drugs- beta blocker, calcium
channel blockers
• Infusion of nitrates
• If medical fails – PCA, CABG
24. MI
• Acute ischaemic necrosis of
myocardium due to occlusion of
coronary artery by atheromatus
plaques
25. Risk factors
• Major risk factors
– Smoking
– HTN
– DM
– Hypercholesterolemia
• Minor
– Type A personality
– OCP
– Male
26. Associated features
• Breathlessness
• Anxiety
• Fear of impending death
• Restlessness
• Nausea and vomiting
• Sweating
• Collapse
• Silent in DM patients
27. Clinical features
• Chest pain
– Site : retrosternal
– Severity : very severe
– Onset : sudden usually at rest
– Duration: prolong
– Character : tight , heavy
– Radiation : Left shoulder
– Relief : not by rest or nitrates only my
morphine
29. Investigation
• ECG – ST elevation, pathological Q
wave, T wave inversion
• Cardiac enzymes – CK – MB
– TROPONIN T and I
– LDH
• Chest x- ray
• Echo
• Coronary arteriography
30. Early management
• Complete bed rest
• Aspirin 300mg chewing
• Clopidogrel 75 mg
• High flow oxygen
• Analgesia – morphine 2.5 to 5 mg
IV
• NITROGLYCERINE
31. – Thrombolytic drugs
Streptokinase
– Anticoagulants – low molecular
weight heparin , subcutaneous
heparin
– Beta blockers : 10 mg iv over 5 mins
or metoprol 5- 15mg iv over 5 mins
followed by oral beta blockers
39. Terminologies
• Systolic hypertension: BP above
140 or more but normal diastolic
pressure
• Cause:
– Old age due to atherosclerosis
– Thyrotoxicosis
– AR
– Exercise
– Emotional stress
40. White coat hypertension
• Transient rise in blood pressure
mainly in patient with borderline
hypertension after seeing a doctor
wearing white coat
41. Etiology of hypertension
• Primary hypertension: in 95% of
cases, the cause in unknown. Such
pressure occurs after the age of 40
yrs and there is positive family
history
• Secondary hypertension: in 5% of
cases, the underlying cause is
known
50. Hypertensive crisis
• Includes hypertensive emergencies
and hypertensive urgencies
• Develops in patient with previous
h/o HTN, but also in normotensive
patient
51. Hypertensive emergencies
• Define as substantial increase in
diastolic BP of greater than 120-130
mm of Hg
• Occurs in 1% HTN patients
• Progressive end organ
complication rather than damage
• BP needs to reduce within several
hours
52. Hypertensive emergencies
• Accelerated HTN-
– Systolic BP exceeding 210 mm of Hg
and diastolic greater than 130 mm of
Hg
– Presenting with headaches, blurred
vision or focal neurological symptoms
• Malignant HTN
– Systolic BP > 210 mm of Hg
– Presence of papilloedema in addition
54. Drug therapy with common
side effects
• Diuretics: furosemide, thiazides,
potassium sparing diuretics.
– Side effects: hypotension,
hypornatremia, hypomagnesaemia,
ototoxicity, gynaecomastia etc
• Beta blockers: propranalol,
atenolol, labetalol, cardivilol
– Side effects: AV block ,aggravate
asthma , Impotence
55. Drug therapy
• ACE inhibitors: Analapril, captopril,
lisinopril etc
– Side effects: postural hypotension,
dry cough, hyperkalemia
• Calcium channel blockers:
Amlodipin, nefedipine, verapamil
– side effects: Hypotension, edema,
headache,
• Angiotensin II receptors blockers:
losartan, valsartan, candesartan
– Side effects: angioedema, allergic
reaction, rashes
56. Congestive heart failure
(CCF)
• Inability of heart to maintain an
adequate blood to meet the body’s
metabolic demand is called CCF
• Accepted as a complex clinical
syndrome charcterized by
dyspnoea and fatigue
57. Precipitating or exacerbating
factors in CCF
• Increase demand:
– Anemia
– Infection
– Fluid over load
– renal failure
– Hepatic failure
– Pregnancy
– Thyotoxicosis
– Arrhythmias
58. Precipitating or exacerbating
factors in CCF
• Pulmonary embolism
• Chronic alcoholism
• Thiamine deficiency
• Uncontrolled HTN
• Drugs
– Beta blockers
– Salt retaining drugs
– NSAIDS
59. Types of heart failure
• Acute and chronic heart failure
– Acute heart failure: develops
suddenly in previously asmptomatic
patients
– Chronic heart failure: develops
gradually over months and years with
compensatory changes
60. Types of heart failure
• Left sided heart failure: reduction
left ventricular out put
• Right sided heart failure: reduced
in right ventricular out put
• Biventricular failure: failure in left
and right side
61. Clinical features
• Ankle edema
• Dyspnoea in exertion
• Cough
• Orthopnoea
• Raised JVP
• Ascites
• Hepatomegaly
• PND, cardiomegaly, frothy sputum
with flex of blood
• Third heart sound, gallop rhythm
62. Right heart failure
• Common cause
– Secondary to LVF
– Mitral stenosisi
– PE
– Cor pulmonale
– Tricuspid incompetence and
stenosis
– Pulmonary stenosis and
incompetence
– Right ventricular infarction
63. Clinical features
• Symptoms
– Fatigue
– Pulmonary symptoms
Breathlessness
Cough with expectoration of frothy
sputum
– Gastrointestinal symptoms
Pain in rt sided of abdomen
Anorexia, nausea and vomiting
– Urinary symptoms
Oilguria, nocturia
64. Clinical features
• CNS symptoms
– Insomnia
– Confusion
– Drowsiness
• Swelling of body, started in
dependent part like ankle, sacram
65. Clinical features
• Signs
– Pt may be dyspnoeic
– Pt adopts propped up position
– Pitting edema
– Raised JVP, positive hepatojugalar
reflex
– Tender hepatomegaly
– Ascites
– Functional murmur of TR
– 3rd heart sound gallop rhythm
69. Left heart failure
• Patient dyspnoeic
• Patient adopts propped up position
• Central cyanosis
• Tachycardia
• S3 heart sound fine crepitation at
the base
• Wheezes
70. Investigations
• X-ray finding left ventricular failure
– Hilar congestion
– Prominence of upper lobe blood
vessels
– Ground glass appearance of alveolar
oedema ( bat’ wing/ butterfly shadow)
– Septal or kerley B lines
– Cardiomegaly
72. Management of Heart failure
• General management
– Bed rest
– Reduction of physical activity
– Salt restricted diet
– Avoidance of alcohols and NSAIDS
– O2 inhalation
74. Complications of heart failure
• Uraemia
• Hypokalemia
• Hyponatraemia
• Impaired liver function
• Thromboembolism
– Deep vein thrombosis
– PE
– Systemic embolism
• Arrhythmia
75. Acute Rheumatic Fever
• Systemic immunomediated
inflammatory disease which is
preceded by Group A beta-
hemolytic streptococcal infection in
throat
76. Aetio-pathogenesis
• Pharyngeal Infection with group A
beta haemolytic Streptococcus
• Production of antibody against the
M protein of streptococcus
• Antigens similar to those in heart
and other tissues
• Cross reacts with heart and other
tissue
77. Clinical features
• Children usually between 5-15 yrs
having a history of sore throat 2 to
3 weeks back
• Presents with fever, anorexia,
lethargy and joint pain
78. Dr. T. Duckett Jones criteria
• Major criteria
– Carditis: involving pericardium,
myocardium and endocardium
(50 to 60)% of patients
Features of carditis: central chest pain,
breathlessness, palpitation, tachycardia,
cardiomegaly, mid diastolic murmer (
carey-coomb’s murmer)
– Polyarthritis : migratory polyarthritis
79. Major criteria
• Erythema marginatum:
– Rapidly enlarging macules that
assumes the shape of rings or
crescents with clear centers
• Subcutaneous nodules :
– Non tender nodules are seen over
bony prominences like elbow, shin,
occiput, spine
– 3-5 % of patient s
– 3 to 6 wks after the onset of Acute
Rheumatic Fever
80. Major Criteria
• Chorea (Sydenham’s chorea)
– Neurological disorder with rapid
involuntary and purposeless non
repetitive movements primarily of the
face, tongue and upper extremities
– only occurs in 3% of cases
– Girls are frequently affected and seen
rare in adults
81. Minor criteria
• Fever
• Arthralgia
• Previous rheumatic fever or RHD
• Essential criteria
– Evidence for recent streptococcal
infection as indicated by
Increase ASO titer
Positive throat culture
Recent scarlet fever
84. Treatment
• Symptomatic:
– Bed rest
– Arthritis : aspirin
– Carditis or arthritis not respond to
aspirin : prednisolone
– Treatment of HF
85. Treatment
• Antistreptoccocal theraphy
• Penicillin
– Procain penicillin 4 lakh i/m BD for 10
days or
– Benzathine penicillin 6-12 lakh i/m
once
– Penicillin allergy: erythromycin
86. Prevention rheumatic fever
• Primary prevention
– Early identification and treatment of
streptococcal infection
• Secondary prevention
– Prevention of recurrence of RF
– inj benzathin penicillin 12 lakh unit
i/m every 3 weeks for 5 years or up to
age of 18 years which ever is longer
– Oral penicillin V 250mg/day 10 days
87. Valvular heart disease(VHD)
• Characterized by damage to or
defect in one of the four valves
• Mitral and aortic are most effected
• Valves become too narrow and
harden(stenotic) to open fully
• Unable to close completely (
incompetent and regurgitation)
88. Classification VHD
• Classified two groups
• Valve stenosis
– Mitral
– Aortic
– Tricuspid
– Pulmonary
• Valve regurgitation with same name
89. Principal cause of valve
disease
• Valve regurgitation
– Congential
– Rheumatic carditis
– infective carditis
– Traumatic valve rupture
– MI
– senile degeneration
90. Principal cause of valve
disease
• Valve stenosis
– Congenital
– Rheumatic carditis
– Senile degeneration
91. Mitral stenosis (MS)
• Almost always in rheumatic origin
• Clinical features
– Symptoms
SoB
Orthopnoe
PND
Palpitation
Fatigue
Cough and hemioptysis
Chest pain, ankle swelling
92. Clinical features of MS
• Physical exmination
– Irregularly irregular pluse
– Mitral facies
– Mid diastolic murmer
93. Diagnosis
• ECG: p mitrale or atrial fibrillation
pulmonary hypertrophy
• Chest x-ray: enlarge left artrium
• Echocardiogram: enlargement of
left atrium and thickening of mitral
valve
94. Treatment
• Diruetics and salt restriction
• Ventricular rate control (B blockers,
digoxin, calcium channel blockers)
• Anticoagulant: to reduce the risk of
stroke
• Mitral balloon valvuloplasty and
valve replacement
95. Mitral regurgitation (MR)
• Retrograde flow of blood from the
left ventricle and to left atrium
during systole
100. Aortic stenosis (AS)
• Second most commonly affected
by rheumatic fever
• Remain asymptomatic for years but
deteriorate rapidly when become
symptomatic
101. Clinical features
• Mild to moderate cases
asymptomatic
• Exertional dyspnea
• Angina
• Exertional syncope
• Episode of acute pulmonary edema
112. Difference between restrictive
and obstructive lung disease
Type of disease Features Causes
Obstructive lung
diseases
Obstruction of small
airways resulting in
increased resistance
to airflow
FEV1/FVC ratio less
than 70%
• Bronchial asthma
• Chronic bronchitis
• Emphysema
• Cystic fibrosis
• Foreign body
• Bronchiolitis
Restrictive lung
diseases
Decrease lung
volumes due to
parenchymal, pleural
or chest wall disease
• Pulmonary fibrosis
• Interstitial lung
disease
• ARDS
• Pneumoconiosis
• Pulmonary effusion
• Pneumothorax
118. Treatment
• General measure
– Rest
– Avoid cold and smokes
– Steam inhalation
– Anti pyretic for fever
– If associated with COPD and asthma,
antibiotics
