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Chapter 83

Ischemic Heart Disease

Jonathan W. Haft

Key Points

1 Because of its unique physiology, the heart is particularly susceptible to ischemic injury.

2 Atherosclerotic plaques cause ischemia from chronic flow limitations or from unstable plaque

rupture.

3 Patients with coronary artery disease will present with either chronic stable angina or an acute

coronary syndrome (ACS), which consists of unstable angina, a non–ST-segment myocardial

infarction, or an ST-segment myocardial infarction.

4 Several well-described complications from myocardial infarctions must be anticipated and recognized

early.

5 Medical treatment of coronary artery disease includes lifestyle modifications and medications to

slow the progression and stabilize atherosclerotic plaques.

6 Percutaneous intervention (PCI) of coronary lesions has improved dramatically in recent years to

include drug-eluting intracoronary stents.

7 Coronary artery bypass grafting (CABG) involves creation of alternative conduits from the systemic

circulation to the epicardial coronary arteries.

8 The left internal mammary artery is the superior conduit for CABG.

9 CABG remains superior to both medical treatment and PCI for patients with left main or three-vessel

disease or for patients with two-vessel disease involving the left anterior descending artery

associated with left ventricular dysfunction.

CORONARY ANATOMY AND PHYSIOLOGY

The right and left coronary arteries originate from the aorta just above the aortic valve cusps (Fig. 83-

1). The orifices of the two arteries within the sinuses of Valsalva designate the right and left coronary

cusps. The third aortic valve cusp is referred to as the noncoronary cusp. The coronary circulation is

traditionally divided into three major territories: The left anterior descending (LAD) and the circumflex

territories originate from the left coronary artery, and the right coronary territory usually comes from

the right coronary artery.

The origin of the left coronary artery is referred to as the left main and travels posterolaterally to the

left behind the pulmonary artery, where it divides into two main branches, the LAD and the circumflex

coronary artery. The length of the left main coronary artery is variable, but rarely exceeds 2 cm.

Unusually, the left main is absent, where the circumflex and LAD originate from the aorta via two

separate ostia.

The LAD coronary artery emerges from behind the pulmonary artery and travels inferiorly within the

interventricular groove to the cardiac apex, sometimes wrapping around it onto the posterior

interventricular groove. The LAD gives off two different types of branches: diagonals and septals, both

of which are highly variable in size and number. The diagonals take off at acute angles and perfuse the

anterolateral surface of the left ventricle. Septal branches, the first of which is typically quite

prominent, emerge at a right angle from the LAD and supply the interventricular septum. The LAD is

the most prominent of the three coronary territories described, and carries approximately 50% of left

ventricular myocardial blood flow, supplying the anterior, anterolateral, septal, and apical walls.

The circumflex coronary artery continues from the left main coronary and travels within the posterior

atrioventricular groove. Branches from the circumflex are called obtuse marginal arteries, and also vary

greatly in size and number. In 80% to 90% of people, the terminal branch of the circumflex supplies the

posterolateral wall of the left ventricle. In the remaining 10% to 20%, the circumflex continues to the

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posterior interventricular septum and terminates as the posterior descending artery (PDA). This is

referred to as a left dominant heart, where the left main coronary artery is supplying the posterior

interventricular septum. Some patients will have a third branch of the left main referred to as the ramus

intermedius, or intermediate branch. If present, this vessel is typically large, and supplies much of the

anterolateral wall of the left ventricle.

The right coronary artery originates from the anterior right sinus of Valsalva and descends in the

right atrioventricular groove. One or more acute marginal branches feed the right ventricular free wall.

In 80% to 90% of patients, the right coronary artery continues to the posterior interventricular septum

and supplies the PDA and often a variable-sized right posterolateral artery. This is referred to as a right

dominant heart. Near the origin of the posterior descending branch, a small characteristic vessel can be

seen supplying the atrioventricular node. This branch can become important in acute right coronary

artery occlusions, resulting in life-threatening heart block and bradycardia. A small proximal branch of

the right coronary artery supplies the sinus node on the anterolateral surface of the superior vena cava.

Anomalous origin of the coronary arteries is common, occurring in 0.3% to 1% of the population, and

their anatomy is varied and complex. Rarely, the left coronary arises from the pulmonary artery. This

pathology is diagnosed in infancy, as the myocardium becomes profoundly ischemic when pulmonary

vascular resistance falls and myocardial perfusion decreases. If left uncorrected, it is universally fatal.

The coronaries may also originate from atypical aortic root sinuses, and their trajectory is variable. The

most worrisome problem occurs when the LAD or left main coronary artery originates from the right

sinus of Valsalva. When the LAD travels posteriorly and to the left, it courses between the pulmonary

artery and the aortic root. This trajectory is described as “malignant” because of the potential for

compression between the great vessels, particularly during accentuated wall stress, such as with

exercise. Although there is little evidence, it is generally accepted that a revascularization strategy

should be considered in symptomatic patients with “malignant” coronary anomalies or in asymptomatic

patients with demonstrable ischemia on noninvasive testing.1

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