Heart Attack : Epidemiology and Risk Factors Epidemiology ~ u n l r r a a u s r i significant coronary artery diseaseU fualiu ~udmriirm 30 i)iihum 6 m m n i ~ I Z l ~ m fiouh:innfi asplrln, beta-blockers ~ S o u i r n 6x1 cardiovascular diseases (ischemic heart 'Iuliu~uni~inm<ihucoronary artery disease 6u disease ua: stroke) f u l h r m ~ l i ~ ~ & ~ m u l h r ~ n f l $?u chronic Sable a n m a ~ ~ d i ~ ~ m > d u 44u ooau.s~8ud+wia UAUIAI a~?jou~ini ia?a~cl&~ilr:iour: 4.13 sinni>anwuoq Proudfit ua~:mflunuaunui~uiiu I A I a a r ~ d ~ : u i ~ i ~ u r : t ~ ~ i h u n ' i i o i ~ s i i n65i i i)iiiioinnau&us:ii mro20 li.riour: 60 E m ~ i n ~ ~ r m r ~ ~ ~ ~ u f l ~ nary ~ ~ artery ~ o u disease n i i u~:~>fIdui?usi?uua:IA'~~?s n i ~ a m a ~ 6 i i ~ ? i u ~ ~ ~ ~ ~ ~ u ncoronary i ~ ~ ~ ~ ~ u iin@uGGni>Au o ~ ~ : ~ u (ulnniiiourr ~ u ~ ~ angiograrn f~u ? ~major u ~coronary u ~ arteries A ~ ~niiu~$u R ~ floq~iu ~ ~ ~ uou D ~ ~ o ~ ~ I > : H ~fIA.. I ~ ~1968-1976 n718AA.IVD.1 ~ i u ~ i i u u aleft r main artery iiEm?ini>~iuEnInu 'lnhlufiom n i ~ g u p ua:nm"nw~?iuA'u~rAm~.~ i ra7iumo~rrii~u <our: 4.1. iouar 7. iour: 12.5 fiaam~H'Em~ini~r7~35mAI~u coronary artery ua: iourr 12.6 niuEii~uiurra:Em~ini~~~~~~ 10 i! &sees ama.rh:mrui~ua': 30 iaur: 24 ur:iourr ~riiKuiourr 62.9, iaur: 45.4. iaurr 23.4 urr 48.6 miu6iih' lm~:~;u?6~6Zj6m~ini~~u;aim~iu+our: 22.5 niu6ii&" d m ~ m ~ i n i ~ ~ 8 u % n I ~ u bu~ud~:~n~unumounri~ur:3nm:Tu~~nn~~~I~d~~~ HAj9lnLiiA myocardial infarmon U$?U~.I~~I: d~:mfldrii6*riRlui dud>: m ~ i + ~ ' EuInijr%f ~ r i ' l ~ l I j i l ~ F5 l : ddi5 ~ ~ U ~ > ~ U I N M ~ ~ ~ U BULEU~n@ud~:rn~m:T~aonnri.r~~ ur:o~uSni~AI' $?u coronmy heart disease srriifl sudden death r r i o u ~ u ~ n i ~ ~ ~ u b u n ~ . r ~ m ~ i n i ~ ~ ~ u i a ?d?ul~~riiariouuiii~I>.~uuiuia muaru~~w En~in~~du%nl H ~ B R ~ ~ D~ A ~ > ~ ~ ~ ~ ~ ~ H ~ A ~ 50) A no9 ischemic heart disease riioqsindxain>lu ~~.muiu?rs:umnmi~Cu~uo~~ud~:7n d . r : ~ n f l ~ ~ a i ~ i i r r ~ ~ n ~ ~ u n i ~ i i ~ ~ ~ n d ~ d u r~lndwounoi ~ u~ m i i rmr I ~ w u innyuu>.rno.rI>~ua:ni?r uir I~nmaon~~o~filsuinGu un>doui+l.rl luariudth7iii intensive care unit &I Epidemiology n e ~ ~ a ~ n a a c i l i ~ a c i l H ' a ~ ~ d o coronary mtery ii atherosclerasis ui& <ihud?u~~~s:ijoinn a n m a pain 61du typical angina s m u i n h r u i ~ i o u r r90 uo.r<d?u $?u acute myocardial infarction ii6n>ini> ~ 3 u E n i i ~ i o u3015 r r ilsqU1VHiqsinii intensive care unit u~:~I>?~M~?uuI beta-blockers. aspirin. ua'?Em>inistAu-Zialu I>urrunnrr~arlb'L6omn'i~~ua: ~'"RuLQuI~~~~I~ thrombolytic therapy d ~ ~ ~ f ~ ~(<70 f inl ) $dii ~myocardial u infarction i ~ u a : 30 n o ~ ~ 1 h ~ d ~ i i i ~ ~ 7 UR:~R'%UI ~tlmul~) t i t u ~ 4 ~ u m u a r i j m n n(mip ~ u ~ ~ckss I) u: mutu 6 d?~u.rucimlniioini7q:a~~m7ld~~d % ~ " m u 1 u 6 & h & ~ i n i i f n m n t o u acute B n l u 35 5iLHkqinfim infarction A ~ ~ A ~ ~ . ~ < Q - infarction, low LVEF (4.40). mngestive heart LUBQJOUA:9.0 [NNT 441) d ~ : T u n M o u n i ~ i n w ~ : ~ ~7~ ~uin1R'ium<i ~iou lvdw 7-12 d?l~qUCi: 13-24 d?~lI4&77d~V4:RA ~NL*&UR: 12.6 ( W ~ ~ D U A12.7 : LUBQ~QUA:11.1 failure, residual ischemia left ventricular hyper- (NNT nophy, axrhythmas. aging (>70 years), diabetes ~DUR: meUitus. dyslipidemia female gender ~ ~ r n r i u u ~ o ~ i t f i stroke l i i m ~U~?.IL?AI 35 myocardd ihTuu8iKdiiuamonn~fin infarction recwrent mymardial infarctim ~ i l ~ d k m s m death la ~ ~ f u ~ : u : ~ u u ~ : ~ :d~:nouWR'?u" u:u~~~u UR: large hyper- 20 ( m i o u ~ :11.3 - 66)) u ~ r i o u a r4.7 ( q i n i o u ~ : 10.5 (NW 10.0 - mfii im 200)) RIuA'IRIU LU~Q 1unt-u: tension n i ~ 5 n ~ 7i ~ dcijqr;iidil-;9'~lis~Y77na~ w LIT-mu 4 dovascular mo~ldity ua: m o M t y 16 %mu n n m u q u u a ~ n ~ " u ~ u a l u ' ~ & nil lR.N. ' 1966 &n5&ujlom:a~ morbidity ua: m o d t y so.r{hu infarction 1"$i ?~fiorn?lH' long term oral tituilu7niiinn~H'hta-blocker u k infarction u h anticoagulant domiinnhrnd&nmu&mrii infarction aiunaafi total mortality (four: 7.9 vs i o u ~ :10.0 (number needed to treat [NNTI - 48)). sudden death (ioua: 3.6 LA: ~ l i f i i Y u n i ~ % ruonqin n~ recurrent $JQI~RR stroke ~ u ~ D ~ myocardial ~ ~ A n17% R ~ anIjarrhythmcs, calcium channel blockers b n u i i l i d ~ : l u a r i ' ~n n r i i coronary angioplasty l u ?hi vs iouar 5.2 (NNT-63)). nonfatal re-infarction $?u (ioua: 5.7 vs i o u ~ :7.5 (NNT = 56))" (NNT AD pain ~ m ~ u ~ ~ d s i o ~ ~ ~ ? u n i 7 i n wmorbidity i ~ r r ' o ut ~i ~u )~ QI~IYUR:LU mortality IR'H~'.IAU) & ~ ~ t w i i u n ~ u ~ ul uui l ~ t w Aumuara'?udu patency rate n.n. 1974 i i ' u i i n n ~ n w i k t h : h ~ h antiplatelets o~ n i 7 l u 5 ~ 1 G n i - 1thrombolytic therapy udBmini7 &d?ulW@D aspm (75-325 m.) fu!$hu myocar- acute myocardial infarction * M anginal single ua: multivessel diseases szan exercise tolerance in'Gniinn?nwi TIO.~URQAL~DR~ lu5u~i~~::ni~~~u~5mlub~nuiuialu'um dial infardon dolcu&4 infarction 3:aA myocar- n i ~ mlate elective angioplasty ~u{1I?udEqiioini7 dial infarction stroke &a: vascular death u & n n r5uHti7~nuAj~iiminfarction W u ~ l u n i ~ ~ ~ O I A ~ i ~ r n u i ? o u ' i ~ ~ o u d ~ m d . ~ d ~ uQUA: ~ ~ u14.7 a~qin n n d u infarction Jimiolridi left ventricular ejec- a a u B o i o u ~ : 11.4 (NNT = 31). nonfatal infarc- tion fraction tud?q7:u:~?ai3 d o u m m i i u n i m i MNT = 72). angioplasty n i u h 18-48 d ? h n h rnfaarcti~n~~ tion q i n <QUA: 4.2 LUBQ AR ~ O U A : 2.8 RR all cause mortality nm'our: 9.5 n i i o i o u r : 8.0 (NNT - 67) uornin6 antiplatelets &RA vascular occlusion rates no4 coronary artery w n i o u a r 27.3 L U ~ D ~ D U A 18.8 : arteries du 7 (NNT - (NNT - 12) &a: peripheral 11P2' d o u l u n.fl. 1980 De Wood n v j i thrombosis n ' i t H ' ~ E ~ n n q ~ 6 u t u U A Q R L ~ ~ D Racute ~U myocardial infarctionn 5uiin-n ~do~rliuu~tuuni~inwiAuui6uni~n'i coronary artery bypass graft f u [ I h u coronary artery disease ~ : ~ R ' d ~ : l u a u l u n i ~ ~ ~ a i n i ~ ~ 5 ~~ uI U~ .L i Eo nR infarction ~ i u a : n ~ ~ m i u ~ i j o ~ ~ u u ~ ~ u u n i r n huuilun-lciid~d?uii left main coronary artery Su > ioua: 50-60 &IW ii three-vessel disease i ? u ~ u i i n i ~ a c l a ~ n o . r n i ~ n ' ileft ~ i u nventricle. ~~ CI intravenous thrombolytic therapy m l f i u n i ~ (d?udi! two-vessel disease ~ n u d u d . r ~ ~ u ~ i ) u n i - d inwi >ioua: 75 no4 left anterior descending a r t e g acute myocardial infarction dyinpi7lu 7 l ~ f i ccontra-indication ~ u n i Y l ~ u(d7:mt-u 6 actors riniimyuu~uaml~nmnnjlY uonnnifRaiuqmou ilss"udw 6o h"diiuarh~kknirnnju i h j , d w h 7 am mrheart disease ti ~mnrjumu'~E~oniadaurilu~>nm5oiiJ~i~nninuin nuu1&lurnmmilmiiu na'ln~uu~uumfuvn?lj~&r h n n atherosdemnio'ty roac plaque rilunuij~nindhR'~~nnur~uolu d>mnsuwrirnii rdu aiakrZuEqGnn { ~ I ~ ? U $ L ~ U ~ ~ ? R ~ ~ ~ ~ > R H A D R L a ~m ~ ~ ~ > ~m ~ a ~o ~ ~~6Um<~U~ q ~~ ~ ~~1I 6~@ ~ 9Zn i 71rbi?qr n 7 iid $mkoy2ullsrmn~v?~uuaz~~5urdw~Aiu n s i r ' d u d w a m n i > l i i m atheroderasis d u onrii~wnmiuumndwrm~a'o~ii i@nrianSurZu il<udusdhKqno.r cardiovascular diseases TRU ii~.rnunmaiuua:Impaired glucose tolerance test ramnohh coronary heart disease, atherothromuinrrj7r~middmiru~mhz~nfl~Zv?n'ubotic stroke H3o peripheral Mscular diseases Risk 2 A ~ R ? ~ ~ ~ R ? I U L < I ~ ~ & ~ ~ ~S P ~ hUR W L ~ W L H ~ W 5&bY0+ fibrinogen r & l u d % h d r o . r " diuannflnmn~ &ua:olau~wqjiimiu8~dfiurn>tiinheart attack iBsnaiurdus~:r6u&riluni~~miu~iuauno~~~4u> m ~ % m a & ~ Y Vfibrinogen jl dii>:&@.rrmdu ddii i1~Lrdu~ddi~~~amu'sn~~~~~~ ~ U ~ D U ~ I > L ~ ~ A ~ > R U R D A L Z ~ D A G ~ ~ ~ U R ~nab$ R U D I fibrinogen m l i l i i m atherosclerosis ua: hliir~nsrhud atherosclerosis ro.nmao~r5io~rinu thrombosis & C & ~ ~ A L W r $ i h n bbfmogen ii ua'a~~rii~ni~msi?u5on1~fiurnnno~ plaque RUI U A ~ N ~ ~ U ~ A U hemmtasis, ~ ~ U ~ ~ blood ~ O theology, mhuii thrombus formation qRfi E A acute platelet aggregation Ua: endothelial function obtmcfion l&umouni~5~~>n1mriiu'ijih4uiuldur~o~ d 4 ~ f i ~ ~ ~ ~ u i ? u n ' h ~ ~ ~ n 7 3 1 ~ 6 ddiK~uuu1A'~h 2 ntju" 6o 1.2 ModiTmble Physiological Risk Fac1. Atherogenic lisk factors tors d>:nmAu 2. Thrombogenic lisk factors Elevated LDL (low density lipoprotein) and low HDL (high density lipoprotein) 1. Atherogenic Risk Factors ZO~~=I<"L~UP~ &un'ud6u atherosclerotic vessels uu.fibr~u3 niu i;o 1.1 Nonmdifiable Risk Factors dlrnou ku luJ~quiriimin3iurilu~uouiun'~l~uh ~rin:6~diimd~n~o~l~iiulihi~~~ul atherosclerosis uar h e m attack Hypertension ~dau~aiu<ul~Gm$~l~ii~:~J~~nfln Age ~untjml~rain~oi~tiounjl 60 il mflniuii atheroderotic events d>rul~RosMimosmfluQ9 n n u u m n m i ~ & r r i o u a ~ u i ~ ~45i niluclrqrwiniu ~i~ ~unjud>zain>iu70 0 & 1 d ~ ~ ~ ~ uQ~oiquindoijouiinaiurdu~~~rr?lm~~nu~ k h 6 u6 0 sudden death ii9aiurrir)lounudnl" ~ ~ ~ ~ u L ~ w L ~ ~ u R W R ? ~ U ~ U Diabetes Mellitus u o n ~ i n l ~ n 1 m m w r ~ ~ u i l q 4 uath~du~ Genetic prediposition erosclerosis uci? ujnuiiiiniar$du~aiu~du~n Davldson3' ~hu.r7uuam~Anmo~uaiunn coronary atherosclerosis uin6u6au~o hypenn- anwilqa.xflA'aiiou 1n'uAo @iaiu~>uuo.r$aui liimhn myocardial bfarcfion loynrdiimq6ounii suhnemia & h u d l ~ ~ o ~ ~ h ~ f l ~ ~ n u ua: low HDL 45 G ~ W ~ U ~ & ~ ~ R ~ > W ~ D R G D R H ~ ~ ~ ~ ~ U ~ R 'nUn~n$nY8 n m ~ ~ n i ~ h u n m m i dmlester01~ ~uumurnr6&k~u~rir)lo~ntjuu~ivu~iivu~ uar NIDDM n u i i ~ d a & ~ u Q ~ u a r n i u i i ~ m ~ i n i ~ obesity. hypertriglyceridemia ~ Y : ~ ~ N R ~ ~ L ~ ~ I ~ ~ ~ ~ ~ ' ~ ~ L ~~IH~U$?U uLUIH?IU" IDDM uh~151rdu.rdoaxormy events r6&urau 4 rmlurnmiu 8 rri71urnmr@qUU 1.3 Modifiable Behavioral Risk F a d o n n l 5 ~ u ~ d uonqinrituil77irdum atherosclerosis d s17Riyu~~Caunujiiin&lk:6~1nCuHDL asw r6u oiglyceride. LDL uc:l fibrinogen 5 s endothelial cell dysfunclion platelets aggregation ~ i & unnn?u?u Sedentary lifatyle n~:u'~~~iin~n)iud~:u~nii~n?i no.rni~~rioonrh&niuKuni~ riis athero~clerosis u m i i n i ~ ~ n w u i n u i u d u ~ ~ ~dluriuinoqni~ ii~n~iu hrirfimu& rillni~r6&oMudwdiq 7 nm atherosclerosis R'€IY:~u~%~u~uL~IR miu6uIais n?iuhur6&uax:ciz1 HDL &olgtero~ asa.rY luiwrn~~iiuhu n i ~ o o n r i i ~ j n i ~ auomin h~u~ ~iunnasih"urduwoatherosclerosis ua:r6u HDL carcholesterol uci?kiiuu?Tu'Ujionasdm~d~~y~rl diovascular death ~R'n"~~unq'umui;ii?~mdni~ unr mu6uhRm~.j[(iCIa1GG d~:nirni/~uqHiiiDIRnni~ l~uil?ViLh:UIN 1.7 rkmosnjun%eu L n n i ~ r i u gimFi?uT~nnaosrPostr;~lqiin~iu8uriu~'I~um~.15~ ndu$xtn& myocardial Infarclionm nnoonrh& R J% N R LIU @ IU ~n~dqu~~~do~iiu~5un~un ~ I% U ~~~uD W R R (regress) coronary atherosclerosis mn'liidmini~ riis corormy artery dsease L h r u l ~ lu{ihudii symptomatic mronary atherosclerosiss5 5 L~~IUA:~~IR sudden cardiac death m m i u " dlwk 2. Thrombogenic Risk Factors idii coronary artery disease HSD myocardial infarcnu?uni~riis thrombus tu¶?lr?ain'ii ~mn~m WDJ i r plaque hduna'lndh6~ds:u'i1d tion u h r i i ~ n q s ~ u n ? i ~ ~ d ~ ~ n ~ ~ n i ~ r i u rupture ~ u n ~ o n i ~infarction ~ i i n dlasa.r**' passive smok{nisriis heart attack tUd?sr?aiRjnii?iiilqjV ncliuau'i.m'riotH'iis thrombus ~ i ~ u ~ s u u ~ 12 r i r ers riiia?iurd~dq:L?Imcoronary events ~6uu'u1A?i9 rnrilk* n $ P " Ao n15&1qsi 2.1 Local vessel wall-related Factors twrurd&biin~qnrjinniu?nrhathero2.1.1 Rheological Factors genic risk factor umwuiin1~6~iina~nli~~iun'u u j r ? ~ i i i i n n b u ~ n ?local : shear rate ~ ~ s @ & ~ c l : ~ o n ~ s i ~ n ? i ~iincnnjiu ~ u ~ : a ~ a uindiln~ ~ ~ ~ 1 ~ platelets ~zauuarriisthrombus ~ I U ~ U qin observahonal studies nVLmi~iu1ulT~ui~d 2.1.2 Degree of Plaque Damage a A h n a w i i m u k ~ ~ r i u n i ~ a s a m ~ COIO~~u%ni~ ujr7nhi damage 6wiisri8~expose tuowo nary hem disease ~ ~ ~ u ~ ~ w I : ~ ~diq~ 7 1 ~ i h~ intima ~ ~ il.rn~:&ua:dqr8julH'fis u ~ ~ R ~ I u throm~ ~ ~ u d a a n o ~ n i ~ a n w ~ ~ 1 u t ~ u n ' u o u i u n ; ? l ~ r d o ~ bus ~ini~ n i ~ ~ l n w n ' t B C ~ ~ i i ~ i n ~ n r i i u ~ n o d q : ~ ~ ~ ~ a ~2.1.3 ~ i i nResidual i ~ ~ ~ Thrombus ~ Y I ~ Udsk M ~ Dprotective factor 'dm atheroscle- n h q l n n l~~ ~ ~ I U ~ ~ ~ ~ U L ~ D A ~ ~ LBDR ujr7~hHtjino9 thrombus da8orjuia'q rosis ~ I ~ & ~ ~ ~ W I U S I H ~ ~ ~ ' ~ V ~ U ~huurini~riisiur'l~Rbu~nu U ~ ~ H ~ O ~ ' cholesterol ann 2.2 Systemic factors iin~iukuKu8riunisriiRatherosclerosis TRU 9 q i n i i n i ~ r ~ & m o s q ~ ncoronary i ~ n ~ ~heart disease ua: peripheral vasdular disease tunq'u 2.2.1 %&VOd a epinephrine L W M U L ~U~U nnrii stress, circadian Mliation n j a n i ~ @ u y n ~ 2.2.2 ~Km0~InUIU1ur~srn Tsuram:~(ii~ d ~ : ~ i n ~ d i i r ~ ~ u i ~ ~ n ~ u cholesterol 6~67ua: lu frsmi'u bpoprotein (a) ILp(a)l ~ i n i ~ ~ ~ ~ d ~ r ~ ~ ~ r i i ~ ~ r i u n ~ ~ 6 i i l J i u i ~ a i2.2.3 n 1 ~~ZR-U n " ~Fibrinogen ~o9 nijsd-~nii~~' ri&u UI:: fador HI -4 W ~ana?.rai~S~ 1. 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