Dr Divya PP
INTRODUCTION
Coronary circulation is the circulation of blood in the blood vessels of the heart muscle (myocardium). The heart muscle needs oxygen-rich blood to function. The coronary arteries which wrap around the outside of the heart, supply blood to the heart muscle.
WHY ARE THE CORONARY ARTERIES IMPORTANT?
Since coronary arteries deliver blood to the heart muscle, any coronary artery disorder or disease can have serious implications by reducing the flow of oxygen and nutrients to the heart muscle. This can lead to a heart attack and possibly death.
CORONARY ARTERY DISEASE
CAD is narrowing or obstruction of one or more coronary arteries because of atherosclerosis which is the accumulation of containing plaque in the inner lining of arteries that decreases perfusion to myocardial tissue and inadequate myocardial oxygen supply which leads to hypertension, infarction, arrhythmias, heart failure and death. (ATHEROSCLEROSIS is a building up of plaque in the inner lining of an artery causing it to narrow or become blocked. It’s the most common cause of heart disease.)
Collateral circulation (more than 1 artery supplying a muscle with blood) is normally present in the coronary arteries, especially in older persons. The development of collateral circulation takes time and develops when chronic ischemia occurs to meet the metabolic demands; therefore, an occlusion of a coronary artery in a younger individual is more likely to be lethal than one in an older individual. Symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia.
CAD is characterized by the accumulation of plaque within coronary arteries, which progressively enlarge, thicken and calcify. Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75%. The goal of treatment is to alter the atherosclerotic progression.
AETIOLOGY AND RISK FACTORS
NON-MODIFIABLE:
Heredity, Race, Increasing age, Gender
MODIFIABLE: Cigarette smoking, Hypertension, Elevated serum cholesterol levels, Physical inactivity, Obesity, Diabetes mellitus, Lack of estrogen in women, Behavior patterns (stress, aggressiveness)
CONTRIBUTING RISK FACTORS: Response to stress, Inflammatory response, Menopause, Homocysteine levels
PATHOPHYSIOLOGY
Due to etiological factors, injury to the endothelial cell Fatty streaks of lipids deposit in arterial wall & Inflammation, immune reactions start T lymphocytes & monocytes infiltrate the area to ingest the lipids & die and also the immune reactions release biochemical substances which damage endothelium that attract platelets to initiate clotting Smooth muscle cells proliferation form fibrous cap over dead fatty core (atheroma) Protrusion of atheroma narrowing & obstruct the lumen of vessel If cap has thin membrane the lipid core may grow and rupture Hemorrhage into plaque & forming thrombus Thrombus obstruct the blood flow leading to sudden cardiac death of myocardial infarction
CLINICAL FEATURES
- Chest pain (Angina pectoris)
Stable angina (typical) – paroxysms of pain related to exertion and relieved by rest or vasodilators. subendocardial ischemia with ST-segment depression
Variant or Prinzmetal’s angina – angina that classically occurs at rest and is caused by reversible spasm in normal to severely atherosclerotic coronary arteries. ST-segment elevation or depression maybe seen during attacks.
Unstable angina – prolonged pain, pain at rest in a person with stable angina, or worsening of pain in stable angina. ST-segment depression (usually) and ST-segment elevation.
Sudden cardiac death – Unexpected death from cardiac causes usually within one hour after a cardiac event or without the onset of symptoms. Usually high-grade stenosis with acute coronary change
- Palpitations
- Dyspnea
- Syncope
- Cough/ hemoptysis
- Dysarrythmias
- Chest heaviness
- Dizziness
- Sweating
- Feeling of Anxiety
- Excessive Fatigue
COMPLICATIONS
Immediate – is a second infarction, which may occur in the domain of another atherosclerotic coronary artery, or in the same zone if there are any live cells left in the infarct.
Chronic
Congestive heart failure
Myocardial rupture
Life-threatening arrhythmia
Pericarditis – As a reaction to the damage of the heart muscle,Ä inflammatory cells are attracted. The inflammation may reach out and affect the heart sac, called pericarditis. In Dresslers syndrome, this occurs several weeks after the initial event.
Cardiogenic shock
DIAGNOSTIC TESTS
- History collection
- Physical examination
- Cardiac Enzymes
Cardiac marker increases, peak return to baseline comments:
Myoglobin 1–4 h, 4–12 h, 24–36 h. Earliest marker, but non-specific with negative predictive value.
CK-MB 4–9 h, 24 h, 48–72 h. Gold standard before troponin was introduced. Mostly found in cytosol but may increase in non-MI situation.
Troponin I/T 4–9 h, 12–24 h, 7–14 days. Most specific marker. Found in small amounts in cytosol, but mostly in sarcomere of cardiac myocytes (both early and late marker). Troponin T is less specific than troponin I because troponin T is also found in muscle.
- Serum cholesterol levels
- Electrocardiograms
- Echocardiograms
- Treadmill Test (TMT)
- Cardiac catheterization or Angiography
MEDICAL MANAGEMENT
Goal – Decrease myocardial oxygen demand
Increase oxygen supply
It include – Pharmacological Therapy, Surgical Management, Lifestyle Changes
Pharmacological therapy:
Nitrates(Nitroglycerine) – to dilate coronary arteries and decrease preload and afterload. These actions help relieve chest pain.
Beta-Adrenergic Blockers (Atenolol, Metroprolol) – decrease myocardial oxygen consumption, decrease heart rate. Increasing the amount of oxygen delivered to the heart increases the chances of survival of individuals having a heart attack. These actions help relieve chest pain.
Calcium channel blockers– help lower blood pressure by relaxing the blood vessels throughout your body. As a result, less pressure is built up and your heart does not have to work as hard to pump blood. (Nifedipine, Amlodipine)
Antiplatelet and anticoagulant agents– to inhibit thrombus formation. (Aspirin, Clopdidogrel)
Antilipid medications (Atorvastatin) to decrease blood cholesterol and triglyceride levels.
Angiotensin-converting enzyme inhibitors (Captopril) to promote a favorable balance of oxygen supply and demand.
Imipramine, morphine sulphate for analgesia.
Folic acid and B complex vitamins to reduce homocysteine levels.
PROCEDURES FOR CAD
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
DIRECTIONAL CORONARY ATHERECTOMY
INTRACORONARY STENTS
LASER ABLATION
TRANSMYOCARDIAL REVASCULARIZATION
Surgical management:
OPEN HEART SURGERY: Cardiopulmonary bypass is used during cardiac surgery to divert the client’s unoxygenated blood to a machine in which oxygenation & circulation occurs. This technique called extracorporeal circulation (ECC) allows the surgeon to stop the heart during time of surgery.
CORONARY ARTERY BYPASS GRAFTING: It involves the bypass of a blockage in one or more of the coronary arteries using the saphenous veins, mammary artery or radial artery.
LIFESTYLE CHANGES
Weight control, Smoking cessation, Exercise, Healthy diet
Health education: Physical exercise, Decreasing obesity, Treating high blood pressure, Eating a healthy diet, Adequate rest, Controlling blood sugar, Decreasing cholesterol levels, Stop smoking, Decrease psychosocial stress, Regular follow-ups, Walk, jogging, or swimming can reduce the risk of mortality from coronary artery disease.
THERAPEUTICS
CACTUS GRANDIFLORIS
Constriction; whole body feels as if caged, with wire being twisted tighter and tighter. Heart feels as if clasped and unclapsed rapidly by an iron hand. very acute pains and stitches in heart; pulse feeble,irregular, quick, without strength. Heart weakness of arterio-sclerosis. Violent palpitation; worse lying on left side.
CRATAEGUS
Said to have a solvent power upon crustaceous and calcareous deposits in arteries. For artherosclerosis and cardiac dropsy. Extreme dyspnoea on least exertion. Pulse irregular, feeble, intermittent.
DIGITALIS
Pulse is weak, irregular, intermittent, abnormally slow. Great weakness and sinking of strength, faintness, coldness of skin, and irregular respiration; Stimulates the heart’s muscle. Pulse weak, and quickened by least movement. The least movement causes violent palpitation, and sensation as if it would cease beating, if he moves. [Opposite; Gels.]
NAJA TRIPUDIANS
Its action settles around the heart; valvular troubles. Hypertrophy, and valvular lesions. Angina pains extending to nape of neck, left shoulder and arm with anxiety and fear of death. Pulse irregular in force. Acute and chronic endocarditis. Palpitation.
AMYL NITROSUM
Praecordial anxiety. Pain and constriction around heart. Fluttering at slightest excitement. Palpitation of the heart and especially the flushing and other discomforts at climacteric. On inhaling this drug, it rapidly dilates all arterioles and capillaries, producing flushing
BUFO
Heels too large. Constriction about heart. Sensation of heart swimming in water. Palpitation.
SPIGELIA
Precordial pain and great aggravation from movement. Pulse weak and irregular. Angina pectoris. Neuralgia extending to arm or both arms. Craving for hot water which relieves. Dyspnoea; must lie on right side with head high.
LATRODECTUS MACTANS
Violent, praecordial pain extending to the axilla and down the arm and forearm to fingers, with numbness of the extremity. Pulse feeble and rapid.
CIMICIFUGA RACEMOSA
Angina pectoris. Irregular, slow, trembling pulse. Numbness of left arm; feels as if bound to side. Heart’s action ceases suddenly, impending suffocation.
LAUROCERASUS
Clutching at heart and palpitation. Mitral regurgitation.
HYDROCYANIC ACID
Violent palpitation. Pulse, weak irregular. Torturing pain in chest. Cold extremities. Angina pectoris. [Spigel.; Oxal. ac.]
CUPRUM METALLICUM
Angina pectoris. Slow pulse; or hard, full and quick. Palpitation, praecordial anxiety and pain. Fatty degeneration. [Phytol.]
LACHESIS- Constricted feeling causing palpitation, with anxiety. Palpitation, with fainting spells, especially during climacteric. Irregular beats.
CROTALUS HORRIDUS
Heart’s action ceases suddenly, impending suffocation.Trembling feeling of heart. Action feeble, pulse tremulous.
KALMIA LATIFOLIA
Palpitation; worse leaning forward. Weak, slow pulse. [Dig.; Apoc. can.] Fluttering of heart with anxiety. Sharp pains take away the breath. Shooting through chest above heart into shoulder-blades.
LACHESIS
Constricted feeling causing palpitation, with anxiety. Palpitation, with fainting spells, especially during climacteric. Irregular beats.
HAEMATOXYLON
Sense of constriction is characteristic. Sensation as if a bar lay across chest. Angina pectoris. Convulsive pain in heart region with oppression.
KALI CARBONICUM
Palpitation and burning in heart region. Sensation as if heart were suspended. Weak, rapid pulse; intermits, due to digestive disturbance. Threatened heart failure.
JUGLANS CINEREA
Pain in chest, axilla and scapula, with suffocative sensation. Feeling as if all internal organs were too large, especially those of left side.
IODUM
Heart feels squeezed, as if by an iron hand [Cactus] followed by great weakness and faintness. Palpitation from least exertion. Tachycardia. Myocarditis, painful compression around heart.
GLONOINE
Palpitation with dyspnoea. Any exertion brings on rush of blood to heart and fainting spells.
OXALICUM ACIDUM
Heart symptoms alternate with aphonia, angina pectoris; sharp, lancinating pain in left lung coming on suddenly, depriving of breath. Praecordial pains which dart to the left shoulder. Palpitation and dyspnoea in organic heart disease; worse, when thinking of it.
FERRUM METALLICUM
Palpitation; worse, movement. Pulse full, but soft and yielding; also, small and weak. Heart suddenly bleeds into the blood vessels, and as suddenly draws a reflux, leaving pallor of surface.
ADONIS VERNALIS
Muscles of the heart are in stage of fatty degeneration, regulate the pulse and increase the power of contractions of heart. Low vitality, with weak heart and slow, weak pulse. Mitral and aortic regurgitation. Myocarditis, irregular cardiac action, constriction and vertigo. Praecordial pain, palpitation, and dyspnoea.
SPONGIA TOSTA
Angina pectoris; faintness, and anxious sweat. Awakened suddenly after midnight with pain and suffocation; is flushed, hot, and frightened to death. [Acon.] Rapid and violent palpitation, with dyspnoea; cannot lie down.
TABACUM
Should prove the most homoeopathic drug for angina pectoris, with coronaritis and high tension (Cartier). Angina pectoris, pain in praecordial region. Palpitation when lying on left side. pain in praecordial region. Pain radiates from center of sternum. Acute dilatation caused by shock or violent physical exertion (Royal). Tachycardia. Bradycardia.
ACONITUM NAPELLUS
Affections of the heart with pain in left shoulder. Palpitation, with anxiety, fainting, and tingling in fingers. Pulse full, hard; tense and bounding; sometimes intermits.
STROPHANTHUS HISPIDUS
Hearts action weak, rapid, irregular, due to muscular debility and insufficiency.
IBERIS
Pulse full, regular, intermittent. Violent palpitation induced by slighest exertion, laughing or coughing. Cardiac dyspnoea.
TARENTULA HISPANIA : Palpitation; praecordial anguish, sensation as if heart twisted and turned around.
REFERENCE
- Davidson’s Principles and Practice of Medicine
- Harrison’s principles of internal medicine
- Textbook of medicine – KV Krishnadas
- Repertory of the Homoeopathic Materia Medica – JT Kent
- Boger’s Boenninghausen Characteristics and Repertory
- Repertorium Homoeopathicum Syntheticum
- Homoeopathic Medical Repertory – Robin Murphy
- www.homeobook.com
