Atherosclerosis

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"When you make a mistake, don't look back at it
long. Take the reason into your mind, and then
look forward. Mistakes are lessons of wisdom.
The past cannot be changed. The future is yet
in your power." Phyllis Bottome 1884-1963,
Novelist and Lecturer
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Anatomy of Heart
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Circulation
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Coronary Arteries
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Pathology of CVS

• Dr. Venkatesh Murthy Shashidhar
• Associate Professor of Pathology
• Fiji School of Medicine.

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Major Disorders of CVS

• Atherosclerosis
• Hypertension
• Myocardial Infarction (MI)
• Stroke
• IHD - Ischemic Heart Disease
• VHD - Valvular Heart Disease
• RHD Rheumatic Heart Disease
• CHD - Congenital Heart Disease

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Atherosclerosis

• Chronic inflammatory disorder of intima of large
  blood vessels characterised by formation of
  fibrofatty plaques called atheroma.
• Hardening of arteries - Arteriosclerosis

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Introduction

• Large elastic arteries Starts in Intima
• Fat deposits, Hardening and destruction.
• Major cause of IHD, MI Stroke.
• Incidence is decreasing since 1995
• Better understanding Change in life style.

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Risk Factors

• Non modifiable
• Age middle to late.
• Sex Males, complications
• Genetic - Hyperchol.
• Family history.

• Potentially Modifiable
• Hyperlipidemia HDL/LDL ratio.
• Hypertension.
• Smoking.
• Diabetes
• Life style, diet, excercise

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Pathogenesis

• Unknown etiology Hyperlipidemia, life style,
  hypertension, smoking, genetic etc.
• Starts with Initial intimal injury,
  inflammation, necrosis, Lipid accumulation,
  Fibrosis - Atheroma.
• Leads to Obstruction or destruction of vessel
• Organ damage due to ischemia.
• Complications - Thrombosis, embolism, aneurism,
  dissection rupture.

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Common Sites

• Aorta, Carotid Iliac. (large vessels)
• Major Vessels - Heart, Brain Kidney.
• Coronary
• Renal
• Abdominal
• Limbs

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Morphology

• Fatty Dots
• Fatty Streaks
• Atheromatous Soft Plaque
• Fibrofatty Hard Plaque
• Complications
• Ulceration, Rupture,Hemorrhage, Thrombosis
• Atheroemboli or cholesterol emboli.

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Stages of Atheroma - Aorta
Stage VI III II
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Coronary Atherosclerosis
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Coronary Narrowing in Atherosclerosis
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Atheroma Aorta
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Atheroma Coronary Artery
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Atheroma Coronary Artery
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Thrombosis Coronary Artery
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Complications

• Heart attack Myocardial infarction.
• Stroke Cerebral infarction
• Gangrene tissue infarction.
• Kidney failure Kidney infarction.
• Aneurysms
• Rupture
• Thromboembolism.

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Angiogram - Embolism Infarction
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Coronary Thrombosis With Infarction
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Cerebral Infarction (Stroke)
Haemorrhagic Necrosis
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Hyperlipidemia

• Hypercholesterolemia Risk
• Hypertriglyceridemia - less significant
• LDL Increased risk
• HDL lowers the risk Reverse transport
• Mobilises the cholesterol from tissues to liver.

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Good Fats

• Mono unsaturated fats
• Poly unsaturated fats
• Omega-3 fatty acids (Fish)

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Lipoprotiens - LDL HDL

• Good and Bad Fats?
• Lower LDL, Increase HDL
• Mono unsaturated fats
• Poly unsaturated fats
• Omega-3 fatty acids (Fish)
• LDL indicate Positive lipid balance, HDL
  negative.
• No Cholesterol in any vegetable oil?

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"Pleasure in the job puts perfection in the
work." -- Aristotle
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Ischaemic Heart Disease

• Common Health problem.
• High Mortality Morbidity.
• Etiology common Atherosclerosis
• Two major types Angina MI.
• Risk factors
• Hypertension
• Hypercholesterolemia
• Diabetes
• Smoking, Life style, Diet, Genetic.

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Patterns of CHD

• Angina Pectoris
• Acute Myocardial Infarction
• Sudden cardiac death

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Pathogenesis

• Obstruction to blood flow.
• Atheroma, Thrombosis Embolism
• Diminished coronary perfusion.
• Ischemia Angina
• Infarction Necrosis
• Inflammation
• Granulation tissue
• Fibrous scarring.

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Myocardial Infarction-MI

• Death of heart tissue due to lack of blood
  supply
• Atherosclerosis is the common cause.
• Coagulative necrosis intact cell shape.
• Severe chest pain, breathlessness sweating
• Complications cardiogenic shock, Death or
  Cardiac failure.

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Gross - Morphology - Micro
Myocardial Infarction-MI

• None
• Edema, inflammation
• Necrosis, granulation
• Granulation tissue
• Dense Fibrosis

• 1-18h none
• 24h Pale, edema
• 3-4D Hemorrhage
• 1-3W Thin, yellow
• 3-6W Tough white

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Coronary Atherosclerosis
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Coronary Atherosclerosis with Thrombosis
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Myocardial Infarction 1 wks.
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Myocardial Infarction - CS
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2wk - Myocardial Infarction - 3d
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MI 2-4 W - Resorption, fibrosis
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Complications

• Cardiogenic shock, death
• Arrhythmias and conduction defects,
• Congestive heart failure (pul edema)
• Mural thrombosis, - embolization
• Myocardial wall rupture, tamponade
• Ventricular aneurysm

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MI - Rupture
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Laboratory Diagnosis

• LDH - 1-5 (1 - 2 flip)
• CK- Isoenzymes (Fractions)
• MM - Muscles
• MB - Cardiac muscle.
• BB - Brain
• Troponins

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Management

• Aimed to prevent complications.
• Rest sedation
• Supportive mesures
• Thrombolytic agents - Streptokinase