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CORONARY VASCULATURE: Sthan Biswas HYPERTENSION AND IHD 4 year intercalating medicCONTENTS 1. Coronary arteries 2. Coronary veins 3. Hypertension 4. Quiz 1 5. Ischemic Heart Disease 6. Quiz 2 CORONARY ARTERIES 1. Sinuses of Valsalva in the aortic semilunar valve 2. Two coronary + One non-coronary cusps 3. Left coronary artery branches: I. Left anterior descending II. Left circumflex branch 4. Right coronary artery branches: I. SA nodal branch II. Acute/Right marginal branch III. Posterior interventricular branch 5. Right + Left dominanceCORONARY VEINS 1. 4 major venous tributaries: 1. Great cardiac vein 2. Small cardiac vein (+ right marginal vein) 3. Middle cardiac vein 4. Posterior cardiac vein 2. All drain into the coronary sinus 3. However, two venous groups drain directly into the right chambers 1. Anterior cardiac veins 2. Thebesian veinsHYPERTENSION – DEFINITIONS 1. Basic definition → SBP >= 140 mmHg + DBP >= 90 mmHg 2. Diagnosis requires = ABPM/HBPM >= 138/85 mmHg 3. Stage 1 HTN → Stage 2 HTN → Stage 3 HTN 4. Malignant HTN I. chest pain, N/V)ency → >= 180/120 mmHG + mild-moderate symptoms (headache, II. Hypertensive emergency → >= 180/120 mmHG + end organ damage (retinal hemorrhage/papilledema, AKI, MI) 5. White coat HTN 6. Masked HTNHYPERTENSION – RISK FACTORS 1. ScHOLARS mnemonic 2. Sc = smoking 3. H = high lipids + high salt + high alcohol 4. O = obesity 5. L = low activity 6. A = age 7. R = race 8. S = sex + stressHYPERTENSION – MECHANISMS Stroke 1. Intravascular volume volume 2. Autonomic nervous system Cardiac Output 3. Renin-Angiotensin-Aldosterone Heart rate system Arterial 4. Vascular mechanisms Pressure Vascular structure PResistance Vascular functionHYPERTENSION – DISORDERS OF HTN 1. Primary HTN (90% of cases) I. Usually asymptomatic II. Patients should be evaluated for end-organ damage III. Must exclude secondary causes of HTN IV. Tx – lifestyle modifications + anti-hypertensive regimen 2. Secondary HTN (10% of cases) I. ABCDE mnemonic II. A – Aortic coarctation + OSA + Adrenal hormone excess (aldo, cortisol) III. B – Bad kidneys (intrinsic parenchymal disease) + bruits in the abdomen (renovascular disease) IV. C – Catecholamine excess (pheochromocytoma) V. D – Drugs + Diet VI. E – EPO + Endocrine (Acromegaly, Thyroid, Hypercalcemia)HYPERTENSION – MANAGEMENTQUIZ 1 1. How many main branches does the left main stem coronary artery have? a) 2 b) 3 c) 1 d) 0QUIZ 1 1. What is the most common cause of hypertension? a) Reno-vascular abnormalities b) Aortic issues c) Idiopathic d) Endocrine pathologyQUIZ 1 1. Which ion determines the extracellular volume of the human body? + a) K b) Na+ c) Ca2+ + d) HQUIZ 1 1. What is the first line treatment for HTN patients > 55 without diabetes? 1. ARB 2. ACEi 3. CCB 4. Beta blockerISCHEMIC HEART DISEASE/CORONARY ARTERY DISEASE 1. Reversible myocardial ischemia 2. Cause = Atherosclerosis 3. Risk factors: a) Diabetes mellitus (DM) b) Family history of premature CAD c) Smoking d) Hyperlipidemia (↑ LDL and ↓ HDL) e) Abdominal obesity f) Hypertension g) Age h) Male gender 4. Types = Stable angina + Variant anginaSTABLE ANGINA– CLINICAL FEATURES 1. Cardinal feature of IHD 2. Occurs when degree of coronary stenosis ≥ 70% 3. Classic Triad symptoms: Substernal chest pain + Precipitated by stress or exertion + Relieved by rest or nitrates 4. Other symptoms: i. Radiation to the left arm, neck, jaw, epigastric region, back ii. Pain not affected by body position + Described as dull, squeezing, tightness, pressure-like iii. Dyspnea + Dizziness iv. Anxiety + Restlessness v. Autonomic symptoms → Diaphoresis, N/V, Syncope, Palpitations 5. Common triggers include mental/physical/emotional distress or exposure to cold 6. Symptoms reproducible with exertion ISCHEMIC HEART DISEASE – FEATURES 1. Diagnosis i. Best initial test → ECG ii. Cardiac enzymes → Normal 2. Differential diagnosis i. Cardiac: ACS, Tamponade, Pericarditis, Endocarditis ii. Non-cardiac: GERD, Costochondritis, Anxiety, Pneumonia, PE, Trauma, Esophageal pain 3. Treatment i. First line → beta blockers ii. Second line → calcium channel blockers, nitrates, ranolazine iii. Secondary prevention → Antiplatelet: Aspirin or Clopidogrel or Dual therapy + ACEi/ARBACUTE CORONARY SYNDROME (ACS) 1. ACS + no ST elevation → NSTEMI + Unstable ECG changes in ACS: angina (UA) 2. Clinical features: I. Symptoms are not reproducible II. Angina at rest + not relieved by rest or GTN III.Severe, worsening angina (crescendo angina) IV. Autonomic symptoms 3. UA → no elevated cardiac biomarkers Treatment: • Analgesia 4. NSTEMI → elevated cardiac biomarkers • Nitrates (Troponin I/T + CK-MB) • Anti-platelet therapy + Anti-coags 5. NSTEMI diagnosed by serial cardiac enzymes + • Beta blocker/ACEi/ARB ECG • Address modifiable risk factorsACUTE CORONARY SYNDROME (ACS) – STEMI 1. ACS + ST elevation + increase cardiac enzymes 2. Affects the full thickness of the myocardium (transmural infarction) 3. Use risk scores to quantify patient prognosis → GRACE, HEART score 4. Dx = ECG!!! → ST elevation or new LBBB 5. Tx = MOAN Big i. Morphine ii. Oxygen iii.ASA + Additional anti-platelet iv. Nitrates v. Beta blockers 6. Patients with STEMI require immediate revascularization → PCI is first line invasive therapy or thrombolysis if PCI is contraindicated or CABGMI COMPLICATIONS DARTH VADER 1. Death 2. Arrhythmia → most common complication of MI 3. Rupture of ventricular wall 4. Tamponade 5. Heart Failure → most acute complication of MI 6. Valvular disease 7. Aneurysm of ventricle → chronic complication 8. Dressler’s syndrome 9. Emboli (mural thrombosis) 10. Recurrence/Regurgtitation (mitral)QUIZ 2 1. How many branches does the right coronary artery have? a) 2 b) 4 c) 3 d) 1QUIZ 2 1. What two variables determine blood pressure? a) SV x HR b) SV x PVR c) CO x Poiseuille’s constant d) CO x PVRQUIZ 2 1. What is an NSTEMI? 1. ST elevation on ECG + increased cardiac enzymes 2. ST elevation on ECG + no increase in cardiac enzymes 3. No ST elevation on ECG + no increase in cardiac enzymes 4. No ST elevation on ECG + increase in cardiac enzymesQUIZ 2 1. What is the most common complication of a MI? 1. LV aneurysm 2. Brain damage 3. Cardiac tamponade 4. ArrhythmiaQUIZ 2 1. What does the ECG show? a) NSTEMI b) Angina c) STEMI d) UATHANK YOU sayan.biswas@nhs.net