Acute Coronary Syndrome Year 4 Internal Medicine Notes

Acute Coronary Syndrome Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / I MED BEAUTIFUL NOTES / CVS -- ● Objectives:\n● Know​ ​the​ ​major​ ​risk​ ​factors​ ​for​ ​atherosclerosis.\n● Understand​ ​the​ ​pathophysiology​ ​of​ ​atherosclerosis.\n● Know​ ​the​ ​classification​ ​of​ ​acute​ ​ischemic​ ​chest​ ​pain.\n● General​ ​approach​ ​to​ ​assessing​ ​an​ ​ischemic​ ​chest​ ​pain.\n● General​ ​approach​ ​to​ ​the​ ​diagnostic​ ​work​ ​up​ ​of​ ​ACS.\n● Know​ ​the​ ​universal​ ​definition​ ​of​ ​myocardial​ ​infarction.\n● General​ ​lines​ ​of​ ​management​ ​of​ ​ACS,​ ​with​ ​emphasis​ ​on​ ​reperfusion​ ​therapy​ ​of​ ​STEMI​ ​including​ ​the\nindication​ ​of​ ​administering​ ​fibrinolytic​ ​therapy,​ ​and​ ​knowing​ ​the​ ​absolute​ ​contraindication​ ​for​ ​its​ ​use.\n● General​ ​understanding​ ​of​ ​the​ ​immediate​ ​and​ ​late​ ​complications​ ​of​ ​STEMI.\n\n ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​[​ ​Color​ ​index​ ​:​ ​ ​Important​ ​ ​ ​ ​Notes​ ​ ​ ​Extra​ ​] ● Resources:\n● 435​ ​slides\n\n [​ ​ ​ ​ ​Editing​ ​file​ ​ ​ ​ ​ ​ ​ ​ ​ ​Feedback​ ​ ​ ​ ​ ​ ​ ​ ​ ​Share​ ​your​ ​notes​ ​ ​ ​ ​ ​ ​ ​ ​ ​Shared​ ​notes​ ​ ​ ​ ​ ​ ​ ​Twitter​ ​ ​ ​ ​]\n\n ● Done​ ​by:​ ​Ahmed​ ​Al​ ​Yahya​ ​ ​ ​Abdulaziz​ ​Alhammad​ ​ ​ ​Khawla​ ​AlAmmari​ ​ Fahad​ ​AlAbdullatif\n● Team​ ​sub-leader:​ ​Mana​ ​Al​ ​Muhaideb\n● Team​ ​leaders:​ ​Khawla​ ​AlAmmari​ ​&​ ​Fahad​ ​AlAbdullatif\n● Revised​ ​by:​ ​Ahmed​ ​Al​ ​Yahya \n\n Anatomy\n\nThe​ ​coronary​ ​circulation The​ ​left​ ​main​ ​and​ ​right​ ​coronary​ ​arteries​ ​arise​ ​from​ ​the​ ​left​ ​and​ ​right​ ​sinuses​ ​of​ ​the​ ​aortic​ ​root, distal​ ​to​ ​the​ ​aortic​ ​valve​ ​(Fig.​ ​18.3).​ ​Within​ ​2.5​ ​cm​ ​of​ ​its​ ​origin,​ ​the​ ​left​ ​main​ ​coronary​ ​artery divides​ ​into​ ​the​ ​left​ ​anterior​ ​descending​ ​artery​ ​(LAD),​ ​which​ ​runs​ ​in​ ​the​ ​anterior​ ​interventricular groove,​ ​and​ ​the​ ​left​ ​circumflex​ ​artery​ ​(CX),​ ​which​ ​runs​ ​posteriorly​ ​in​ ​the​ ​atrioventricular​ ​groove. The​ ​LAD​ ​gives​ ​branches​ ​to​ ​supply​ ​the​ ​anterior​ ​part​ ​of​ ​the​ ​septum​ ​(septal​ ​perforators)​ ​and​ ​the anterior,​ ​lateral​ ​and​ ​apical​ ​walls​ ​of​ ​the​ ​LV.​ ​The​ ​CX​ ​gives​ ​marginal​ ​branches​ ​that​ ​supply​ ​the lateral,​ ​posterior​ ​and​ ​inferior​ ​segments​ ​of​ ​the​ ​LV.​ ​The​ ​right​ ​coronary​ ​artery​ ​(RCA)​ ​runs​ ​in​ ​the right​ ​atrioventricular​ ​groove,​ ​giving​ ​branches​ ​that​ ​supply​ ​the​ ​RA,​ ​RV​ ​and​ ​infero-posterior aspects​ ​of​ ​the​ ​LV.​ ​The​ ​posterior​ ​descending​ ​artery​ ​runs​ ​in​ ​the​ ​posterior​ ​interventricular​ ​groove and​ ​supplies​ ​the​ ​inferior​ ​part​ ​of​ ​the​ ​interventricular​ ​septum.​ ​The​ ​RCA​ ​supplies​ ​the​ ​sinoatrial (SA)​ ​node​ ​in​ ​about​ ​60%​ ​of​ ​individuals​ ​and​ ​the​ ​AV​ ​node​ ​in​ ​about​ ​90%.​ ​Proximal​ ​occlusion​ ​of the​ ​RCA​ ​therefore​ ​often​ ​results​ ​in​ ​sinus​ ​bradycardia​ ​and​ ​may​ ​also​ ​cause​ ​AV​ ​nodal​ ​block. Abrupt​ ​occlusions​ ​in​ ​the​ ​RCA,​ ​due​ ​to​ ​coronary​ ​thrombosis,​ ​result​ ​in​ ​infarction​ ​of​ ​the​ ​inferior part​ ​of​ ​the​ ​LV​ ​and​ ​often​ ​the​ ​RV.​ ​Abrupt​ ​occlusion​ ​of​ ​the​ ​LAD​ ​or​ ​CX​ ​causes​ ​infarction​ ​in​ ​the corresponding​ ​territory​ ​of​ ​the​ ​LV,​ ​and​ ​occlusion​ ​of​ ​the​ ​left​ ​main​ ​coronary​ ​artery​ ​is​ ​usually fatal.\n\n Pathophysiology​ ​and​ ​risk​ ​factors​ ​ ​of​ ​atherosclerosis\n\n ● Introduction: Myocardial​ ​ischemia​ ​occurs​ ​when​ ​the​ ​oxygen​ ​demand​ ​exceeds​ ​the​ ​supply.​ ​The​ ​most​ ​common​ ​of​ ​that​ ​is obstructed​ ​coronary​ ​artery​ ​in​ ​the​ ​form​ ​of​ ​coronary​ ​atherosclerosis[​ ​It​ ​is​ ​also​ ​known​ ​as​ ​coronary​ ​artery disease​ ​(CAD)​ ​].\n\n ● Pathophysiology:​ ​ ​(Endothelial​ ​cells​ ​are​ ​central​ ​to​ ​the​ ​pathogenesis​ ​of​ ​ACS)\n- It’s​ ​a​ ​complex​ ​inflammatory​ ​process​ ​characterized​ ​by​ ​an​ ​intimal​ ​plaque​ ​that​ ​obstructs​ ​the​ ​blood\nflow.​ ​It​ ​consists​ ​of​ ​:​ ​1)​ ​Necrotic​ ​lipid​ ​core.​ ​ ​2)​ ​Fibromuscular​ ​cap.\n1) Lipid​ ​core​ ​formation​:​ ​It​ ​starts​ ​with​ ​endothelial​ ​damage​ ​and​ ​ ​increased​ ​permeability​ ​that​ ​allows\nleakage​ ​and​ ​accumulation​ ​of​ ​oxidized​ ​lipids​ ​into​ ​the​ ​intima.​ ​Resulting​ ​in​ ​formation​ ​of​ ​flat​ ​yellow​ ​dots\nor​ ​lines​ ​on​ ​the​ ​endothelium​ ​called​ ​“fatty​ ​streaks”.​ ​Those​ ​lipids​ ​are​ ​then​ ​taken​ ​up​ ​by​ ​the​ ​macrophages\nresulting​ ​in​ ​formation​ ​of​ ​“foam​ ​cells”.\n2) Fibromuscular​ ​cap​ ​formation​:​ ​Cytokines​ ​are​ ​released​ ​such​ ​as\nPlatelet-derived​ ​growth​ ​factor​ ​(​PDGF)​ ​and​ ​ ​Transforming​ ​growth\nfactor​ ​beta​ ​(​TGF-β)​ ​from​ ​the​ ​macrophages​ ​and​ ​damaged\nendothelial​ ​cells.​ ​Resulting​ ​in​ ​further​ ​accumulation​ ​of\nmacrophages​ ​+​ ​migration​ ​and​ ​proliferation​ ​of​ ​smooth​ ​muscle\ncells.​ ​Then​ ​collagen​ ​is​ ​produced​ ​with​ ​large​ ​amounts​ ​from​ ​the