ISCHAEMIC HEART DISEASE

Imbalance between supply & demand of

myocardium for oxygenated blood.
Results
Hypoxia
Inadequate supply of nutrients
Inadequate removal of metabolites
Causes
Reduced coronary blood flow(90%)
Increased myocardial demand: Tachycardia, hypertrophy
Hypoxia
Anaemia, advanced lung disease, cyanotic heart disease,
carbon monoxide poisoning, cigarette smoking,
 Reduced coronary blood Flow
Atherosclerosis(95%)
Narrowed coronary ostia
Atheroma of ascending aorta
Syphilitic aortitis
Dissecting aortic aneurysm

Vasculitis of coronary arteries

SLE, IE, PN, HIV, Takayasu, Kawasaki

Thrombo-Embolism: IE, Mural thrombosis

 Atherosclerosis (Atheroma)

Deposition of lipid in the intima eventually

leading to elevated fibrofatty plaques
Over 90% of coronary artery disease
leading to IHD
50% of all deaths in US attributable to
atheroma
The coronary artery shown here has narrowing of the lumen
due to build up of atherosclerotic plaque. Severe narrowing
can lead to angina, ischemia, and infarction.
 Atheroma:
Sites
Medium sized muscular arteries and large elastic
arteries
Abdominal aorta
Coronary arteries
Popliteal arteries
Descending thoracic aorta
Internal carotid arteries
Circle of Willis

Vessel lumen compromised

 Atheroma: Predisposing factors
Increases with age
Positive family history
Hypercholestorolaemia
low density lipoproteinaemia vs high density lp
Hypertension
Diabetes
Cigarette smoking
 Atheroma:Pathogenesis
Response to injury
? Chronic repeated endothelial injury

Endothelial dysfunction
? Increased permeability to plasma lipids etc
 Atheroma:Morphology
Fatty streaks
Atheromatous plaque
white yellow intimal lesions up to 1.5cm protruding
into lumen

Micro
Fibrous cap
Underlying necrotic core, smooth muscle cells, lipid
material and inflammatory cells
Periphery of proliferating small vessels
 Atheroma: complications
Calcification
Ulceration/fissures leading to thrombosis
Haemorrhage into plaque
Cholesterol microembolization
Aneurysm formation
 CLINICOPATHOLOGICAL
SYNDROMES of IHD
Determined by rate and severity
1. Angina pectoris
2 Ischaemic cardiomyopathy
3. Myocardial Infarction
4. Sudden death
 ANGINA PECTORIS
Transient ischemia not resulting in infarction
Stable angina
Triple vessel disease> 75% narrowing
Severe paroxysmal pain on exertion
Relieved by rest or medication
No infarcts but severe coronary atheroma
Unstable angina
Thrombosis and occlusion -------- MI
Prinzmetals angina
Pain at rest
Spasm of coronary arteries
arrythmias
 ISCHEMIC
CARDIOMYOPATHY
Later decades of life
Slow progressive reduction in Coronary
blood flow (5 to 10 years)
Diffuse fibrotic changes in myocardium
Maybe episodic angina/ MI
Usually silent and presents with failure
 Myocardial Infarction
Death of myocardium due to reduced blood
supply
Anterior descending 40-50%
Ant. Wall of left ventricle.
Ant. 2/3 of interventricular. Septum
Rt coronary art. 30-40%
Post wall of left ventricle.
Post 1/3 of interventricular. Septum
Lt circumflex
Lateral wall of left ventricle.
 TYPES OF INFARCTS
Transmural
-endocardium to pericardium

Subendocardial
-inner 1/3 of myocardium
-multiple foci of necrosis
 MI: Sequence of events
Up to 12hrs- biochemical changes only
12hr- polymorphs infiltrate
24hrs pale infarct
2-4 days borders hyperemic/ infarct yellow
4-10 days- infarct yellow necrotic
10 days- progressive replacement by
fibrous tissue
3wks-3mths infarct converted to scar
In this microscopic view of a recent myocardial infarction,
there is extensive hemorrhage along with myocardial fiber
necrosis with contraction bands and loss of nuclei.
This myocardial infarction is about 3 to 4 days old. There is
an extensive acute inflammatory cell infiltrate and the
myocardial fibers are so necrotic that the outlines of them
are only barely visible.
 Complications of Infarction
Arrhythmias most frequent Cause of death
Cardiac failure- extensive infarction of left vent.
Mural thrombosis- release of tissue
thromboplastin from damaged muscle
Rupture of lt vent (myomalacia cordis)
Cardiac tamponade
Ventricular aneurysm
Fibrosed weakened vent wall
Recurrence of infarction
 SUDDEN DEATH:
(sudden cardiac death)
Death within 24hrs ( usually within 1 hr) after
onset of symptoms in person previously well
Pathogenesis
Rhythm disturbance
Severe sudden outflow obstruction
Causes
Coronary atheroma(commonest)
Coronary malformation- anomalous origin etc
Outflow obstruction
Hypertrophic cardiomyopathy
Aortic stenosis
Pulmonary embolism
Conduction system defects
CONGENITAL
 Mitral Valve prolapse
Myocarditis
Aortic Valve Stenosis
Hypertrophic Cardiomyopathy
Conduction System abnormalities