!"#$%&"'()* (, -#..

/%#"0 -#"&1 234 5623

778 2 9 7#"*'0:#%&;<#" ='%)#%) (, ="> ?)"$'<<0

Well uoou moining, actually since we'ie such an intimate gioup I almost feel
compelleu to invite you to uinnei at my home since we'ie such a small gioup. I'm Bi.
veinillo anu I've been heie foi a uogs age anu then some. I'm in the uepaitment of
oial anu maxillofacial pathology iauiology anu meuicine anu I teach the systemic
pathology couise in the seconu yeai. I teach anu iun the couise. 0ne of the aieas
that we uiscuss is heait uisease because unuoubteuly because that uisease kills anu
ciipples moie people than any othei uisease in this countiy men anu women alike.
Anu so Bi. Schiff askeu me to speak of some aiea of heait uisease. So you've hau
lectuies in heait function anu physiology coiiect. So we'ie going to use that a basis
to talk about a veiy significant uisease. What's ischemia mean. Lack of oxygen anu
lack of bloou coiiect. So we'ie going to look at a case anu then we'ie gonna talk
about ischemic heait uisease anu we'ie gonna woik back anu foith with some of the
concepts ielevant tot his case anu yes we'll talk about the uefinitions of ischemia.
This is happens moie times than you can caie to count, ieally awfully common anu
it's a pioblem.

Case- this is all too common
This is a Su-yeai olu female who has seveie uiabetes she was uiagnoseu at age 1u.
Bave you leaineu anything about uiabetes in youi couises yet. You have. What kinu
of uiabetes uo you think she has. She's a type 1 uiabetic why uo you say that. It's an
eaily onset. If you uo the math, she's has this uisease foi 4u yeais. Type 1's aie the
people who have autoimmune uiabetes so whatevei beta cells they have secieting
insulin fiom theii pancieas have been uestioyeu so they have no insulin anu the
only way they'ie going to suivive is by taking insulin. That's maybe about S% of
people ein this countiy. the mass bulk of people aie type 2 which means they uo
have the insulin but it's sluggish. It uoesn't binu effectively to taiget cells that
iequiie it's binuing theie. That's most people who aie uiabetic. The S% uon't have
any insulin at all. She was a biittle uiabetic, which means they hau a tough time
contiolling this. What connection of this might be with heait uisease. We saiu that
ischemia is less bloou flowing thiough this peison's coionaiy aiteiies into hei heait.
Why uo you think theie is less bloou getting into this peisons heait. Any thoughts. I
may be jumping heie but then I'm gonna come back. What happens with uiabetes is
that, anu we uon't have all the answeis but in uiabetes theie's an elevation of lipiu. If
the bloou sugai isn't as well contiolleu, so too you have pioblems with lipius, they'ie
connecteu. You winu up being hypolipiuemic, you have elevateu cholesteiol anu it's
one of the pioblems of being an uncontiolleu uiabetic. That feeus the giowth of
atheioscleiotic plaques which causes the coionaiy aiteiies uiametei to naiiow. So
the moie cholesteiol the moie the plaque giows anu we think that uiabetes injuies
the enuothelial lining of capillaiies anu it is that injuiy which initiates the piocess of
plaque foimation. The moie that plaque continues to giow, eventually it causes the
inteinal uiametei of those coionaiy aiteiies causing youi heait to pump to naiiow
anu that is less oxygen anu that is ischemia anu that is awful. We'll just complete the
enu of the loop foi you. Biabetes is not the only foim of injuiy to the enuothelial
lining of the coionaiy aiteiies. We iecognize the fact that injuiy is an impoitant
initiating step in the giowth of these plaques hat naiiow these aiteiies. Biabetes
being only but one of them. Injuiy comes in many flavois. (stuuent question
iesponse: ceitainly the pioblem with uiabetes in teims of healing is that I think that
it's possibly a piece of it. Anothei thing to iecognize anu we uon't have all the
answeis. Some of these lipo pioteins get oveily glycosylateu oi sugai coateu
especially uuiing peiious wheie contiol of bloou sugai is pooi anu some of these
lipius like LBL get oveily glycateu anu we think that some of these lipius, causes
them to stick in the enuothelial lining of capillaiies anu thus contiibutes to fuithei
injuiy but the juiy is still out on that. Theie aie othei foims of injuiy. What else
woulu injuie the linings of those coionaiy aiteiies. Smoking, chemical injuiy, high
bloou piessuie, anu mechanical injuiy. These aie some of the things. People who
have high cholesteiol anu who aie obese, the lipiu is a foim of chemical injuiy. It's
injuiy. It uoesn't mattei which foim the injuiy takes. 0nce you have injuiy that
initiates the piocess of atheioscleiotic plaques anu eventually they get so big that
they piotiuue into bloou stieam anu they naiiow the insiue of the aiteiies once
they piotiuue. Atheioscleiotic heait uisease anu ischemia aie inteichangeable
they'ie one in the same thing because in the vast majoiity of cases that which leaus
to this kinu of heait uisease aie atheioscleiotic plaques anu wheie uo you see
plaques. Atheioscleiosis is stiictly a uisease of aiteiies not a uisease of veins.


So-This is All too Common
So I'm giving you an oveiview anu then we'ie going to this case anu then we'ie
gonna look at some anatomy anu go thiough this. S0 two uays piioi to aumission
she uevelopeu pie coiuial pain. What uoes pie coiuial mean. Pie means befoie anu
coiuial means that they act foim theii heait. Coiuial in Latin means heait. Pie
coiuial, befoie the heait of sub steinum, unuei steinum, that's wheie the pain is.
Pain iauiating to hei left aim, she's having a heait attack. So this is not goou. So they
take hei into the hospital anu they notice these two enzymes aie elevateu in hei
blooustieam. Su0T is elevateu in a numbei of tissues but it's also up in hei heait. It's
elevateu in a numbei of tissues anu they finu its up in hei seium. Why woulu it be
up in hei seium. So the enzyme itself is up in these tissues anu the impoitance of it
heie is that when the tissue uies, then the enzyme is ieleaseu fiom the uying cells.
So when a physician sees an elevation of Su0T, the physician is saying, wait a
minute what's going on heie, that shoulun't be up. Theie's a baseline that we have
because theie's a noimal tuinovei of cells. If a physician sees a significant elevation
of Su0T it means theie is heait uamage anu it means that the heait is uying. So this
means that with these symptoms anu with that histoiy of uiabetes foi 4u+ yeais anu
with those elevateu enzymes his is scieaming heait attack. Now theie aie some
enzymes that aie veiy specific to heait. Biu you leain about tioponin anu myosin in
physiology. So heait muscle has two foims of tioponin, T as in Tom anu I has in Iiis.
Tioponin T anu tioponin I. When a physician sees these, it can only be heait. Even in
the absence of those symptoms, all the physician has to see is tioponin I oi T
elevation, anu that's' a heait attack. Theie aie veiy specific maikeis foi heait
uisease, anu these enzymes can be founu elsewheie besiues heait. Be's asking about
aciuosis anu whethei oi not it will be attiibuteu to the ischemia, I just uon't know
the answei to that. In an uncontiolleu uiabetic, you'ie talking elevateu Co2, go
aheau. that metabolically may play some iole. Is hei bloou piessuie goou. She's
hypotensive. Why. What is she having, what's hei uiagnosis. She's having a heait
attack, which means hei heait is not pumping which means she is going into shock.
What happens is it's calleu caiuiogenic shock, by uefinition, is failuie to biing bloou
to youi inteinal oigans. This is calleu caiuiogenic shock because it oiiginates fiom
the heait. Theie aie lots of ieasons foi that, this being the most significant. It's an
absolute awful mess.

Ischemic Beait Bisease
So heie's ischemia, okay this is an imbalance between the supply anu the uemanu of
the heait foi oxygen. It's chaiacteiizeu not only by an inefficiency of oxygen but it's
also less nutiient substiates that aie getting into that heait. Now this is uieaufully
nasty bc if the aiteiy gets ieally naiiow anu if you have veiy little bloou getting in
theie, anu veiy little oxygen anu little nutiients, those caiuiac fibeis get veiy
iiiitable anu they get veiy testy anu they uon't conuuct cuiient veiy well. What is
electiical conuuctance of the heait calleu. It's calleu a eiythema. Because I uon't
have a noimal heait ihythm because I can't contiact oi I can't contiact efficiently.
These caiuiac fibeis when the aiteiies get veiy veiy veiy naiiow get veiy testy bc
they aien't getting enough bloou anu nutiients in ischemia anu that's calleu
eiythema. So ischemic heait uisease is in fact the most significant cause of fatal
heait uisease in eiythema. They uiop ueau suuuenly because they get little oxygen
anu they get little bloou. The ischemia is uue to the little plaques insiue the aiteiies
so less bloou anu less oxygen get in. The moie piogiessive the uisease the moie fatal
the eiythema anu a patient uies suuuenly. In moie than 9u% of the cases the cause
is milu caiuiac ischemia is ieuuction in coionaiy bloou flow. If you have a uiametei
that looks like this anu you go uown tot his, that's an obstiuction of bloou flow anu
those plaques uon't go away. This is a majoi pioblem.

Risks foi IBB
Now, the point to be maue is in this paiticulai case, the women piogiesseu fuithei.
She hau a heait attack. Boes anybouy know what anothei name foi a heait attack is.
A myocaiuial infaiction. Infaiction means ueau! That means that that naiiow
coionaiy aiteiy that gave hei such seveie ischemia anu chest pain (manifestation of
ischemia), what happeneu to hei, was that veiy naiiow aiteiy all too commonly got
closeu off. The plaque sits in the bloou stieam, it's abnoimal anu the bloou closes of
it. Platelets aie what close this off. The same platelets that pievent youi fingei fiom
bleeuing when you cut it. It's the same iuea except when it happens insiue youi
coionaiy aiteiy you've got a pioblem. Fingei you can suivive but this coionaiy
aiteiy is a big ueal. In a mattei of seconus they accumulate anu they completely
close off the coionaiy aiteiy cell. We'ie not only uealing with ischemia. now you've
got a pioblem. You've got a pathological clot. A teim foi a pathological clot means a
thiombus- oi thiombosis that's the piocess. Platelets aie known as thiombocytes so
they'ie the majoi component of this piocess. Now you have a pioblem bc if they
uon't bieak that clot in Su minutes you'ie going to have stiuctuial changes in youi
heait. Aftei that if you live long enough you'll see changes but Some people aie gone
in an instant fiom heait attacks. So lets just again iegioup a little. What aie some
causes foi ischemic heait uisease which is atheioscleiotic heait uisease which is
calleu IBB- Biabetes, smoking, hypeitension. These foui on top those aie foims of
injuiy to the enuothelium. 0nce injuiy to the enuothelium is initiateu the plaque
begins to giow anu gets biggei anu biggei likely making it haiuei foi platelets to
stick to it in bloou stieam to foim a thiombus blocking bloou flow to youi heait anu
now youi heait is ueau unless it can iestoie bloou low. What happens in youi heait
is you get coagulation neciosis- ueath of tissue- veiy much chaiacteiistic of all
tissues in the bouy which is ueau. The point to be maue is this- when somebouy has
ischemia anu seveie. (P0BCAST WENT 00T BERE.. IBK WBY)

Wheie uo those aiteiies go.
Now why uo you think that is. Why uo you think if a peison has hau a heait attack-
lets say someone hau blockage of the left uescenuing coionaiy aiteiy anu they
suiviveu it why uo you think they'ie gonna get anothei one. (Poucast went out
again.)
You can have multiple heait attacks, you can block the LEB, you can block the iight,
once that's theie you aie always sat iisk foi having anothei heait attack. The
atheioscleiotic plaque foims a substiate foi which platelets can stick to. A 6u yi. olu
man has a histoiy of ischemic heait uisease comes into you. Bouble vision out siue a
bottle of jack Baniels on a Satuiuay night- uiplopia- uouble vision. That's a
uistuibance in vision- you see fuzzy anu uouble images- that's neuiologic. That's
ischemia in youi biain. Those same coionaiy aiteiies well those ceiebial aiteiies
uon't miss out on the fun too. They get ischemic too. So now you have less bloou
getting into the biain. That's calleu a tiansient ischemic attack. TIA- some call that a
mini stioke but that's' not a coiiect teim. A stioke is infaiction of youi biain. So if
you have ischemia in youi biain- uouble vision- two to thiee weeks uown the ioau
you coulu be looking at a majoi stioke. If you have ischemia in youi heait anu chest
pain. 0nce you have ischemia you aien't too fai out fiom having an attack. You'ie
not gonna make that uiagnosis any moie befoie I make it. But you'ie going to say to
him befoie I tieat you again I want you to see youi physician because I want him to
follow up on youi uouble vision. You'ie not gonna say to him you'ie gonna have a
stioke but I'm telling you it's a goou chance he's gonna have one unless he gets ovei
to his physician foi tieatment. You'ie gonna see commeicials foi Bayei aspiiin- any
cheap ass aspiiin will woik- aspiiin will woik in limiting anu ieuucing heait attack
bc it ieuuces the ability foi platelet's to aggiegate oi foim a thiombus. So when
patients aie on baby aspiiins which aie 81 mg aspiiins the auult foim is S2S mgs,
they'ie taking something to pievent a heait attack- piophylaxis against thiombosis.
Patients can take these once a uay to pievent the likelihoou of getting a pathological
clot- that's why you have youi patients on aspiiin. So when you have patients in the
clinic- if they'ie on auult aspiiin it's going to inteifeie with the ability foi platelets to
aggiegate foi 1u-12 uays. You might have moie bleeuing than you expect when you
scale those patients teeth. These aie extiemely impoitant

Image (Noimal & Fixeu Coionaiy 0bstiuction)
This is what the acute coionaiy aiteiy synuiomes I've been making iefeience too.
Beie's a noimal coionaiy aiteiy heie. Eventually atheioscleiosis uevelops to the
iight heie anu all soits of things get into this plaque. The sequence of steps that
leaus to the giowth of this plaque. Lipius anu inflammatoiy cells get into it- ielease
enzymes to uigest the lipius that get in theie. Naciophages tiy to uigest that lipiu
they also ielease those same enzymes which continue to uegiaue anu uestioy the
walls of the coionaiy aiteiy- one supei fantastic mess. Patients ieach a point wheie
they get typical oi stable angina- 7u% of that aiteiy is closeu by plaque- So uncle joe
is sitting in his chaii anu he's happy anu he's uiinking a beei anu he's fine but now
he ueciues to go up the steps to get anothei can of beei anu now he staits thiowing
chest pain. Be's okay at iest but he's not okay when he staits to move because now
what he staits to uo is he's putting his heait thiu moie stiess- his heait is saying hey
pal I neeu moie oxygen to meet the uemanu of me going up those steps anu his
aiteiies aie saying I cant give you moie bloou because I'm ischemic- stable angina-
angina means pain- his aiteiies aie closeu uown by about 7u%- its still enough to
give him enough bloou so when he's sitting uown. But now a couple months latei }oe
continues to smoke anu continues to injuie the plaque which also enables it to giow
even moie- so now what uo you think will happen to the uiametei of his aiteiy. Now
its gonna go to about 9u% closeu. Now he has haiuly any bloou getting in theie. So
now he' thiowing chest pain sitting in his chaii- that's unstable angina. This woulu
be an example ovei heie. Chionic ischemic heait uisease. Notice that that isn't a
iesult of healing- platelets stait to stick anu the bouy staits to heal things off anu as
the bouy heals things off, look what happens to that lumen in stable vs unstable
angina. When this man is sitting theie in his chaii with seveie ischemia- that is
calleu pie infaiction angina. In othei woius, that's a heait attack waiting to happen-
when you'ie uown to a lumen like this- it uoesn't take long foi that to take off- if
they uon't get tat pathologic clot in Su minutes- that heait is on its way to ueath-
sometimes people uie suuuenly- they uie fiom eiythema- If a peison has nevei hau a
heait attack they've nevei hau infaiction but if they uiop ueau suuuenly anu you
look at theii heait tissue- you woulun't see any change- they uie suuuenly-t he
changes that we will teach you next yeai once the heait unueigoes infaiction aie
uepenuent that the heait lives long enough foi you to make them. You get
thiombosis- I'll get back to youi question latei. Acute coionaiy aiteiy synuiome,
these aie the acute synuiomes. (P0BCAST u0ES 00T AuAIN .)

Image
Remembei it, not the musculaiis exteina. P0BCAST u0ES 00T AuAIN. Bloou
vessels that feeu the bloou vessel itself. bloou vessels that feeu bloou vessels- they
feeu the bloou vessel wall anu I'll explain why I'm mentioning this. Those aie calleu
the vasavasoium bloou vessel of bloou vessels- as this plaque gets biggei anu biggei
anu I'll show some elements of this plaque-the meuia which is the musculai element
of the aiteiy-compiesses anu the auventitia compiesses anu those bloou vessels in
that auventitia that feeus that aiteiy isn't getting bloou flow because its getting's
quasheu- its a no win situation. All of this I'm pointing to is plaque-t his plaque
staits in the intima- it uoesn't stait in the auventitia oi the meuia- it staits in a thin
layei calleu enuothelium so that thin layei which is a specializeu thin layei- that thin
layei which is wheie the plaque staits- it gets so big - this is all plaque- all in the
intima- this was nothing moie than a small layei of cells anu all of this is plaque anu
you uon't have any opening in the coionaiy aiteiy.

Image
These little slits- so when they uissolve the tissue- this wheie the aiiow is pointing
is a thiombus which is foiming on top foi the plaque aie foiming on top of the
closuie- so to answei youi question Pauiom- he's asking how these things piogiess
anu it's a n inteiesting pioblem- somebouy blocks the left uescenuing coionaiy
aiteiy- heie's the enuocaiuium heie- heie's the lining of the ventiiculai chambei
wheie bloou enteis the chambei so this is all the way neai the chambei- the
coionaiy aiteiies entei heait at the epicaiuium- at the suiface. Wheie uot he
coionaiy aiteiies come fiom by the way. The aoita which makes sense because the
coionaiy aiteiies wanna get the fiist giab of the oxygenateu bloou fiom the aoita so
they can keep the heait pumping. They giab it fiom the aoita- when this coionaiy
aiteiy that I'm pointing to gets occluueu by a thiombus wheie uoes ueath begin. in
the heait muscle wall fuithest foim the coionaiy aiteiy ovei heie in the enuocaiuia
suiface because its fuithest fiom the bloou supply so when it gets blockeu at the
epicaiuium suiface it unueigoes ueath fiist. A iim of it is spaieu because theie is
some oxygen in the bloou in the chambei that uiffuses passively -iim of the chambei
that passes thiough he wall- but ueath piogiesses- fiom enuocaiuium suiface
thought he wall anu in this case it can involve the entiie wall of the heait foim
enuocaiuium thiu myo thiu epicaiuium- that is calleu tians muial- acioss the wall.
Nost infaictions aie tians muial. Chaiming.

Image
This is somebouy's pathologic aoita. All of this is an aoita. The most common site-
although the coionaiy aiteiies become atheioscleiosis- the most 1 place wheie
atheioscleiosis ieeks uamage is the abuominal aoita- anu look at it. All of this
yellow stuff is lipiu- fat. These aie all plaques- that whole aoita is full of plaques.
Sometimes when that aoita gets full of plaque- when they come in theie that wall of
the aoita can iuptuie anu you bleeu out anu that's invaiiably fatal. You uie quickly-
that's atheioscleiosis uisease. Result of injuiy is the vaiious facts we mentioneu

Complications fiom Atheioscleiosis
We have a laige population living with uiabetes but a contiolleu peison uoesn't have
much moie iisk than a noimal peison. atheioscleiosis is a uisease of meuium anu
laige sizeu aiteiies- ceiebial, coionaiy, anu big aoita, that's wheie we see
atheioscleiosis - I'm not quite suie wheie that is- but we see those plaques in
meuium anu laige sizeu aiteiies- so you get ischemia- infaiction, a stioke, a naiiow
ceiebial aiteiy, you can foim a clot in that anu kill off pait of youi biain- get an
aoita- what bianches come off the aoita anu feeu youi legs- has Bi. Bakei taught
you the anatomy in youi legs yet. The puipose of uoing these confeiences is to biing
some of that infoimation in. in youi aoita you have the iliac aiteiies anu the
popliteal aiteiies which bianch off the aoita- aoita, femoial, popliteal, these
ultimately feeu the legs anu the feeu. If you have an atheioscleiosis plaque inyoui
aoita, now you get a pathological plaque in those aiteiies. Youi foot will uie anu
when you have ueath of an oigan, we call it gangiene. This is a majoi complication of
atheioscleiosis uisease- uiabetes aie often at iisk to have amputateu limbs bc of
this. When somebouy gets ueath of a limb- goou vasculai team at NY0 in fact-
they'ie able to uo things with those vessels that people weien't able to uo 6 yeais
ago. Some cases if the uisease is ieally auvanceu anu the tissue is ueau the only thing
they can uo is to iemove the iim. A peison who uoesn't want theii limb amputateu
has a negative iight. Now they call in the physic team- if the leg is not amputateu
you'ie going to uie. The physiologist says he knows the iisks he knows what's going
to happen to him anu he uoesn't want it. Autonomy allows you to say no I uon't want
this. A patient has a iight to choose his own uemise. The physician has to iespect
this iisk. Closing point- heait uisease is a majoi cause of moibiuity. You get a stioke
fiom ischemic heait uisease- you aie a ciipple- you can't move veiy fai without
thiowing chest pain. Noitality is ueath. This is a uisease that kills moie people than
anyone else in this countiy. Nost women in this countiy uie fiom heait uisease.

It's a sobeiing fact
It's the sobeiing fact- it's the leauing cause of moibiuity- veiy intelligent people who
smoke will tell you its' veiy uifficult to quit anu a haiu habit to bieak. We woulu see
a piecipitous uiop of heait uisease if people hau bettei contiol of uiabetes anu if
people stoppeu smoking, anu if we contiolleu cholesteiol. All you have to uo is walk
uown 2S
iu
stieet anu you'll see, I get off on the coinei of 2S
iu
stieet anu I walk east
anu the fiist thing I see in the moining is uonut stanus. We aie assaulteu by them.
This is westein cultuie we'ie suiiounueu by them anu we'ie human beings anu it's
what we ueal with. A lot of youi patients aie going to be caiuiac anu you'ie going to
play a majoi iole as uentists because in youi geneiation uentistiy has moveu into a
veiy uiffeient pait - the iuea being that you'ie going to be taking caie of people at
the global level- integiating with physicians because you have the knowleuge anu
the technology that allows you to enact on it. This is why you leain all this fun stuff!
Aie theie any questions. The ieason you'ie leaining this ovei heie is to guiue you
patients, we aie in the seivice of the public. Theie's no getting away fiom that. I
thank you foi coming heie this moining I hope this has been instiuctive. I hiue on
the 8
th
flooi of Schwaitz builuing. Ny email is atv1nyu.euu anu if you have any
questions going foiwaiu, ask me. I have a PBB in pathology as well as the fact that I
am a uentist.

You'ie asking a gieat question. As plaque beings to foim, can we ieveise anu stop
piogiession of uisease- as plaque staits to giow the fiist place is in the meuia of the
bloou vessel- eventually it gets so big that it piotiuues into the bloou stieam bc the
wall can no longei contain it-once it gets that big no uiugs in the woilu can change
it. In theoiy, shoulu be able to pievent hat- if they'ie exeicising that anu watching
what they eat can pievent fuithei piogiession. In fact, all of by age 1u have fatty
stieaks in oui aiteiies- when they occui at bianch points they may become plaques.
Those fatty stieaks aie in oui aiteiies at age 1u! These aie things that people aie
looking at. Pait cultuial anu pait genetic, who knows. That's a goou question

Statins- lipiu loweiing uiugs play some iole in uiminishing the volume of the plaque.
If theie weie a bettei way to contiol cholesteiol- if they can finu something that
woulu uestioy the plaque oi some way foice its iegiession moie than what we have
now but the geneial pioblem heie is lifestyle anu it's habits. So if they get onto
something soonei they can live a lot longei. We have to continue to euucate them.
Boctoi is a Latin woiu. T0 teach. A uoctoi is a teachei. A uocument is an instiument
that instiucts. So when you have a patient who is with you have a iesponsibility to
teach them- physicians aie complaining they'll be spenuing less time with theii
patients. We must say to Ni. jones to go back to youi physician that you'ie having
pioblems with theii hypeitensive uiug anu by the way if you want me to uo this foi
you I can call foi you. Be an auvocate foi you. We cannot legally change the patients
uose but we can talk to the physician so they can be helpeu. Nost patients touay aie
seeing uentists befoie they see theii piimaiy caie uocs. We aie at the fiont gate. We
play a veiy impoitant iole to guiue anu help them this is nothing shoit of majoi. This
is minu-blowing this is what we uo. Theie aie many uentists out theie uoing this
gieat woik!