Treatment of Coronary Heart Disease

Treatment objectives are :

»Improving prognosis by preventing myocardial mikard and death. Efforts are made is how to reduce the occurrence of acute thrombotic and left ventricular dysfunction. This goal can be achieved by lifestyle modification or pharmacologic interventions that will : 

a. Progressively reduce plaque

b. Stabilize the plaque, by reducing inflammation and improving endothelial function

c. Prevent thrombosis when endothelial dysfunction occurs or plaque rupture. Drugs used are antithrombotic drugs such as low-dose aspirin, ADP receptor antagonists (thienopyridin) of clopidogrel and ticlopidine; cholesterol-lowering drugs (statins), ACE-I nhibitors; Beta-blockers: Calcium channel blockers (CCBs).

»To repair simstom and ischemia, a drug used is working Nitrate short and long term, beta-blockers, CCBs.

 General Procedures

To patients who suffer from coronary cardiac disease or family, should be indicated on the course of the disease, the choice of drugs available. Patients should be reassured that most cases of angina can be improved with medication and lifestyle modifications so that the quality of life could be better. Comorbid disorders such as hypertension, diabetes, dyslipidemia need to be handled properly and correctly. 

Method of Treatment of coronary heart disease :

• Pharmacologic Treatment

 • Myocardial Revascularization

How to Diagnosis Coronary Cardiovascular Disease

Diagnosis

The first step in the management of acute coronary heart disease is the establishment of a definite diagnosis. Precise diagnosis is important, because if the diagnosis of coronary heart disease have been made therein contained the sense that the sufferer has a chance to experience cardiac infarction or sudden death. wrong diagnosis always has bad consequences on quality of life of patients. In young people, restrictions on physical activities that are not in place may be advised.

Besides their chances of getting a job may be reduced. If this happens to older people, then they probably should have retired too early, should be repeatedly hospitalized to eat excessively or potential drug toxins for long periods of time. On the other hand, fatal consequences can occur when the presence of coronary cardiovascular disease are not known or if the presence of other cardiovascular diseases that cause angina pectoris missed and go undetected.

 How to Diagnosis

The following table will show the ways the diagnosis of coronary heart disease, whether currently existing or potential in the future will have a major role. Physicians should choose whatever checks that need to be made ​​to the patient to achieve maximal diagnosis (right) with minimum risk and minimum cost.

 Diagnosis ways :

1. Amnesis
2. Physical Examination
3. Laboratory 
4. Photo of data.
5. Non-invasive examination of Cardiovascular :

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• Resting ECG
• Physical exercise test (treadmill)
• Train the Physical Test Combination Imaging :

1. Physical exercise test echocardiography (Stress Echo) 
2. Physical exercise test myocardial perfusion Scintiography
3. The combination of physical exercise test pharmacologic imaging technique

• Echocardiography break
• ECG monitoring ambulatoar
• Non-invasive technique of determining the classification of the coronary and coronary anatomy:

1. Computed Temography 
2. Magnetic Resonanse arteriography

   6. Invasive testing to determine coronary anatomy

1. Coronary arteriography
2. Intra Vascular Ultrasound (IVUS)

Pathophysiology of Coronary Heart Disease

Endothelial layer of normal coronary arteries will be damaged by the presence of risk factors, among others: hemodynamic factors such as hypertension, vasoconstrictor agents, mediators (cytokines) from the blood cells, cigarette smoke, atherogenic diet, increased blood sugar levels and oxidation of LDL-C. 

This damage causes the endothelial cells produce a cell adhesion molecule such as silicon (interleukin -1, (IL -1)); tumor necrosis factor alpha (TNF-alpha)), chemokines (monocyte chemoattractant factor 1, (MCP-1; IL-8 ), and growth factor (bFGF). Cells Inflammation as Monocytes and T-lymphocyte entry into the endothelial surface of the endothelium and migration into the sub-endothelial. Monocytes then differentiate into macrophages and take LDL and then the macrophages become foam cells .

Oxidized LDL causes endothelial cell death and result in inflammatory responses. In addition, there was the response of angiotensin II, which cause vasodilation and trigger protombik effects involving platelets and coagulation factors.

As a result of endothelial damage occurred and formed a protective response fibrofatty and fibrous lesions, plaques atherosklerosik triggered by inflammation. Plaques that occur can be unstable (vulnerable) and ruptures that could lead to acute coronary syndrome.

Risk Factors for Coronary Heart

Risk Factors That Can’t Be Changed	Risk Factors Can Be Modified
Age	Smoking
Gender	Hipertension
Family History	Dyslipidemia
Ethnic	Diabetes Mellitus
	Obesity and Metabolic Syndrome
	Stress
	The High-Fat Diet Calories
	In Physical Activity
New Risk Factors
Inflammation
Fibrinogen
Homocysteine
Oxidative stress

Coronary Cardiovascular Disease

Coronary Cardiovascular disease is a cardiovascular disease which is mainly caused by narrowing of the arteries coronary due process of atherosclerosis or spasm, or a combination of both. Coronary Cardiovascular disease is a very scary and still be a problem both in developed and developing countries. The survey results showed that the prevalence of coronary cardiovascular disease increased from year to year. The cause of death also tends to change from infectious diseases to cardiovascular diseases such as coronary cardiovascular disease and degenerative. 

Clinical manifestations of classical coronary cardiovascular disease is angina pectoris. Angina pectoris is a clinical syndrome in which chest pain arising obtained at the time to do activities because of ischemic myocardial . This indicates that there has been> 70% narrowing of the coronary arteries. Angina pectoris may appear as stable angina pectoris ( stable angina) and this situation could develop into more severe and cause acute coronary syndrome, known as sudden cardiac arrest (heart attack) and can cause death.

The definition of Coronary Cardiovascular  Disease

Stable angina pectoris is a symbol of the clinic which is characterized by discomfort in the chest, jaw, shoulder, back or arm, which is usually triggered by physical work or emotional stress. All that can be reduced by rest or by nitroglycerin medication. 

 Prinzmetal Angina is chest pain caused by coronary artery spasm, This is often occur at rest time, is not related to physical activity and sometimes cyclic (at the same time each day). 

Acute Coronary Syndrome is a clinical syndrome that has the same basic pathophysiology that is the erosion, fissures, or atheroma plaque rupture, causing intravascular thrombosis leading to an imbalance of supply and myocardial oxygen demand. 

Types of Acute Coronary Syndrome are:

1.  Unstable angina pectoris (unstable angina) are characterized by suddenly chest pain and more severe, the attacks much longer (more than 20 minutes) and more frequently. Angina is emerging (less than one month), angina that arises within one month after infarction are also classified in unstable angina. 
2. Acute myocardial infarction is the pain of angina in acute cardiovascular infarction are generally more severe and longer (30 minutes or more). Nevertheless cardiac infarction can occur without chest pain (20-25%). Miokad acute infarction can be nonQMI (NSTEMI) and Q-wave MI (STEMI).

The Benefits of Using Protons in Cancer Therapy

Different from the X-rays, protons by the energy setting will afford the maximum energy deposited in the tumor tissue of the prostate gland, with a relatively very small doses in the small intestine and urinary bladder. Irradiation from the side with a beam of x 18 MeV, then a lot of energy deposited in the hip bone, while the proton can deposit energy in the prostate with minimal radiation to normal structures. The advantage of concentrated dose also occurred in treatment of tumor on the inner eye, as in ocular melanoma. Treatment with proton very effective and satisfying as it can save a variety of sensitive tissues of the eye, so the patient's vision is not impaired. In the conventional treatment for this case is to lift the patient's eye, which in addition can also resulted in the appearance of defects of vision loss. This method has a lot of help cure cancer in the brain, head and neck of the womb. 

Therapy with a proton with a unique character in terms of clinical benefit in cancer control and handling, can contribute significantly to healing and pain reduction as well as in patients. The accuracy of this technique can be further enhanced if supported by imaging techniques, to be able to confirm the volume and position of the target irradiated want, especially in certain parts such as head and brain. With the availability of such equipment include X-ray Computed Tomography (CT Scanner) and Magnetic Resonance Imaging (MRI), the medical experts can calculate the position and size of the tumors, to conduct a more effective therapy.

With very less damage to healthy tissue, then the potential for side effects like nausea, dizziness and diarrhea post-irradiation becomes greatly reduced. By taking as many as 20 fractions of radiation, patients can undergo irradiation only once a day, 5 times a week, so for the entire treatment takes one month. It could be said that the cancer with proton therapy is a new noninvasive way with huge potential.

Biological Effects of Radiation

 At the center of each atom in all molecules or materials including cancer cells, there is a nucleus, surrounded by negatively charged particles or electrons. If a high-energy charged particles such as protons or other forms of radiation on the orbital electrons, then protons a positive charge will attract negative charge of the electron, and removing it from the orbital called the ionization event. Ionization events will change the characteristics of atoms and characteristics of these molecules will be changed.Transformation is  the concept of utilization of all ionizing radiation for therapy, because the events of ionization, radiation can lead to damage to molecules in the cell, including DNA as genetic material, which continues to damage to vital functions of cells is the process of cell division. Theoretically, the enzyme may help cells to recover DNA damage, but in terms of damage is quite intensive, the enzyme no longer able to repair the damage. In such cases, cancer cells are permanently damaged leading to the death to the next. 

Biological effects of various types of radiation does not only depend on the dose given, but also depend on the microscopic distribution of the usual dose is expressed as a linear energy transfer (LET), which is equivalent to dE / dx. Charged particles such as protons have a high LET compared with photons. Similarly, price of relative biological effectiveness (RBE). Depending on the amount of energy, the proton RBE ranged from 1-16, while the RBE (photon = 1. Thus, with proton radiation is more effective than with photons.