Atherosclerosis

What and how?

Faris Basalamah,MD, FIHA

 Aims of Presentation
• Understanding definiton and pathogenesis
of atherosclerosis
• Understanding symptoms and risk factors
of atherosclerosis
• Understanding concept and pathogenesis
of acute coronary syndrome
 Aterosklerosis
• Athero : Lemak,
Sclerosis : Pengerasan / penebalan,
jaringan parut

• Aterosklerosis : proses inflamasi menahun dan

progresif akibat penumpukan kolesterol di
dinding arteri
Proses Kompensasi Pembesaran Arteri
Koroner
Progression

Expansion
overcome :
lumen narrows

Normal Minimal Moderate Severe

vessel CAD CAD CAD
Faktor Risiko Penyakit Jantung Koroner

 Usia : Tua > Muda

 Gender : Laki-laki > Perempuan
 Riwayat Keluarga ( PJK )
 Merokok
 Hipertensi
 Diabetes Mellitus
 Diet : Tinggi Lemak Jenuh dan Kolesterol
 Peningkatan Kadar Kolesterol Total dan LDL
 Kadar Kolesterol HDL Rendah
 Obesitas
 Kurang Aktivitas Fisik
 Risk Factors for Atherosclerosis
Hypercoagulable states Life-style (e.g., Hyperlipidemia
smoking, diet, lack of
exercise)
Homocysteinemia Hypertension

Diabetes Infection?

Obesity Endothelial Age

Genetics dysfunction Gender

Atherothrosclerotic
American Heart Association. Heart and Stroke Facts: 1997 Statistical Supplement; Wolf. Stroke 1990;21(suppl 2):
II-4–II-6; Laurila et al. Arterioscler Thromb Vasc Biol 1997;17:2910-2913; Grau et al. Stroke 1997;28:1724-1729;
9 Graham et al. JAMA 1997;277:1775-1781; Brigden. Postgrad Med 1997;101(5):249-262.
 Atherosclerosis Timeline
Foam Fatty Intermediate Atheroma Fibrous Complicated
cells streaks lesion plaque lesion rupture

Endothelial Dysfunction
From First Decade From 3rd decade From 4th decade

Growth mainly by lipid accumulation Smooth Thrombosis

muscle and hematoma
collagen
Stable Plaque Atherosclerosis
Unsteable Plaque Atherosclerosis
 Gejala Penyakit Jantung Koroner

Nyeri kardiak PJK memiliki 3 komponen nyeri :

• viseral - bersifat tumpul dan sulit

terlokalisasi

• somatik - lebih tajam dan memiliki distribusi dermatomal

• psikologis - bersifat subyektif, perasaan akan datangnya ajal,

kesedihan yang mendalam dan ketakutan
yang tidak spesifik
 Gejala Penyakit Jantung Koroner

• Angina klasik
Rasa tidak enak di daerah substernal, sifatnya tumpul,
seperti ditekan / diperas, menjalar ke lengan kiri / leher,
dapat disertai kesulitan bernapas, berdebar-debar, keringat,
mual atau muntah

• Angina Equivalent
Tidak ada nyeri / rasa tidak enak
di dada yang khas,
namun pasien menunjukkan
gejala gagal jantung mendadak
(sesak napas),
atau aritmia ventrikular
(palpitasi, presinkop, sinkop)
Atherothrombosis: Thrombus Superimposed
on Atherosclerotic Plaque

Adapted with permission from Falk E, et al. Circulation. 1998;92:657-671. Slide reproduced with permission
from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Atherothrombosis:
a Generalized and Progressive Process
Plaque Unstable
Athero-
Normal
Fatty
streak
Fibrous
plaque
sclerotic
plaque
rupture/
fissure &
thrombosis
angina
MI
}ACS
Ischemic
stroke/TIA

Critical leg
Clinically silent
ischemia
Stable angina
Intermittent claudication Cardiovascular
death
Increasing age
ACS, acute coronary syndrome; TIA, transient ischemic attack
 Characteristics of Unstable and
Stable Plaque
Unstable Stable
Lack of
Inflammatory inflammatory
cells cells
Thin Thick
Few fibrous cap More fibrous cap
SMCs SMCs

Intact
Eroded endothelium
endothelium
Activated
macrophages Foam cells

Adapted with permission from Libby P. Circulation. 1995;91:2844-2850. Slide reproduced with permission from
Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
 Correlation between frequency of plaques, degree of
stenosis, and risk of complication per plaque as a
function of plaque progression

Although the average absolute risk of severely stenotic plaques may be higher than the average absolute risk of
mildly stenotic plaques, there are more plaques with mild stenoses than plaques with severe stenoses.
 Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion

Thrombus Formation

Old
Terminology: UA NQMI STE-MI

New Non-ST-Segment Elevation Acute ST-Segment

Terminology: Coronary Syndrome (ACS) Elevation
Acute
Coronary
Syndrome
(ACS)
Heart Attack

20
 Timing of Release of Various Biomarkers
After Acute Myocardial Infarction

Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3 rd ed. Rochester, MN:
Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:773–80. 22
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 5.
 Sequence of Events in Ischemic
Heart Disease
• Arrythmias
• Lost of muscle
• Angina MI
• Silent Ischemia
Remodeling

CAD
Progresif dilatation

Endothelial dysfunction
Heart Failure
Death
Risk Factor
Terimakasih
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