Download Assessment and management of patient with coronary artery

Blood supply of the heart .
 Tow
coronary arteries arise from
the aortic sinuses :

The right coronary artery .
 The left main coronary artery .
 The
right coronary artery branches
into :

Right marginal artery .
 Posterior descending artery .
 The
right coronary artery supplies
right atrium ,right ventricle and
bottom portion of both ventricles
and back of the septum .
 The
left main coronary artery
quickly branches into two large
arteries :

Circumflex artery .
 Left anterior descending artery .
 The
left coronary artery supplies
left atrium, left ventricle and the
front of the septum.
Coronary artery disease (CAD)

Coronary artery disease is one of the most
common and serious effects of aging.

Atherosclerosis narrow the passageway
for the movement of blood.

This stenosis often leads to eventual
blockage of the coronary arteries and a
“heart attack” .
Risk factors
Uncontrollable :
controllable :

gender

hypertension

Hereditary

Diabetes

Race

hyperlipidemia

Age

Smoking

Physical activity

Obesity

Stress and anger
Presentation of patient with
CAD :

Asymptomatic (silent CAD).
 Stable angina .
 Unstable angina .
 Myocardial infarction .
Asymptomatic CAD

It may not be diagnosed until a person
shows signs and symptoms of a heart
attack, heart failure, or an arrhythmia .

It is usually associated with type 2
diabetes mellitus .
Stable angina
 Coronary
ischemia is due to
imbalance between blood supply and
oxygen demand .
 It
occurs when oxygen demand
exceeds blood supply .
Clinical features
 Chest
pain or substernal pressure
lasts less than 10-15 minutes .
 brought on by exertion or stress .
 relived by rest or nitroglycerin .
Diagnosis
 Stress
tests .
a.
Stress ECG : recording ECG before, during, and after
exercise on a treadmill . Positive findings include ST
segment depression, chest pain, hypotension or ventricular
arrhythmias .
b.
Stress ECHO : performed before and immediately after
exercise . It is positive if there is wall motion abnormality
not present at rest .
c.
Pharmacologic stress test : IV adenosine or dobutamine
can be used to induce cardiac stress instead of exercise and
combined with ECG, ECHO or nuclear perfusion imaging .
 Cardiac
catheterization with
coronary arteriography .

most accurate method of identifying the
presence and severity of CAD .

Main purpose is to identify patients with
significant CAD to determine the need of
revascularization .
Treatment
Risk factor modification :






Quit smoking .
Control hypertension .
Control diabetes .
Control hyperlipidemia .
Weight loss and exercise .
Reduce intake of saturated fat and cholesterol .
Medical therapy .





Aspirin.
Beta blockers .
Nitrates .
Calcium channel blockers .
ACE inhibitors and diuretics if heart failure
present .
Revascularization .
Percutaneous coronary intervention (PCI) .
 Coronary artery bypass grafting (CABG) .

Unstable angina
 Blood
supply is decreased secondary
to reduced resting coronary flow .
 In
contrast to stable angina , oxygen
demand is unchanged .
Clinical features



Angina at rest .
Chronic angina with increasing
frequency, duration or intensity of the
chest pain .
New onset angina that is sever and
worsening .
Diagnosis
 History
.
 Stress tests .
 Cardiac catheterization with
coronary arteriography .
 Diagnostic workup to exclude
myocardial infarction .
Treatment
Hospital admission
 Medical therapy :







Oxygen
Morphine
Nitrates
Aspirin
Beta blockers
Catheterization/Revascularization .
After the acute treatment
 Continue
aspirin, beta blockers
and nitrates .
 reduce the risk factors .
Myocardial infarction
 Necrosis
of the myocardium as a
result of an interruption of blood
supply .
 Most
patients with MI have a history
of CAD or arrhythmias .
Clinical features
Asymptomatic .
 Chest pain .
substernal crushing pain radiating to the
neck, jaw or left shoulder and arm .
 Other symptoms like dyspnea, weakness,
syncope, nausea and vomiting .

Diagnosis
 ECG
.
 Cardiac enzymes ( CK-MB and
Tropnins ).
Treatment
Admission to the CCU .
 Medical therapy :









Oxygen
Morphine
Nitrates
Aspirin
Beta blockers
ACE inhibitors
Statins
Heparin
Revascularization .
 Benefit
is highest if performed early .
 Should be considered in all patients .
 Two forms of revascularization :
thrombolysis or PCI .
Angioplasty

a non-surgical treatment used to open
narrowed coronary arteries to improve
blood flow to the heart.

It can be performed during a diagnostic
cardiac catheterization when a stenosis is
identified, or it may be scheduled after a
catheterization has confirmed the presence
of coronary artery disease.
 Once
the catheter is in place, one
of these interventional
procedures is performed to open
the artery:





balloon angioplasty .
Balloon angioplasty with stenting.
Drug-eluting stents (DES) .
rotablation .
cutting balloon.
Balloon angioplasty (PTCA)
a small balloon at the tip of the catheter is
inserted near the stenosed area of the
coronary artery.
 When the balloon is inflated, the plaque is
compressed against the artery walls and
the diameter of the blood vessel is widened
to increase blood flow to the heart .
 sometimes complicated by vessel recoil and
restenosis .

Balloon angioplasty with stenting
(PCI)
balloon angioplasty is performed in
combination with the stenting procedure.
 stent is a small, metal mesh tube that acts
as a scaffold to provide support inside the
coronary artery.
 the balloon is inflated and the stent
expands to the size of the artery and holds
it open.
 The balloon is deflated and removed, and
the stent stays in place permanently.

Drug-eluting stents (DES)
Drug-eluting stents contain a medication
that is actively released at the stent
implantation site.
 Drug-eluting stents have a thin surface of
medication to reduce the risk of restenosis.

Rotablation (Percutaneous Transluminal
Rotational Atherectomy or PTRA)
A special catheter, with an acorn-shaped,
diamond-coated tip, is guided to the point of
narrowing in the coronary artery.
 The tip spins around at a high speed and
grinds away the plaque on the arterial walls.
 This process is repeated as needed to treat
the blockage and improve blood flow.
 microscopic particles are washed safely away
in your blood stream and filtered out by your
liver and spleen.

Cutting balloon
The cutting balloon catheter has a
balloon tip with small blades.
 When the balloon is inflated, the blades
are activated. then, the balloon
compresses the plaque into the arterial
wall.

Coronary artery bypass
grafting (CABG)
Indication for surgery :







Left main artery disease or equivalent .
Triple vessel disease .
Abnormal Left Ventricular function .
Failed PCI .
Immediately after Myocardial Infarction (to help
perfusion of the viable myocardium).
Life threatening arrhythmias caused by a previous
myocardial infarction.
Occlusion of grafts from previous CABGs.
 Most
common
arteries
bypassed:
 Right coronary artery
 Left anterior
descending coronary
artery
 Circumflex coronary
artery
Conduits used for bypass :

Saphenous vein used for bypassing right
coronary artery and circumflex coronary
artery .

Internal mammary artery (IMA) used for
bypassing left anterior descending coronary
artery .
Steps of the procedure
Harvesting the grafting vessle .
 Median sternotomy .
 Heparin administered to minimize clotting
 Cardiopulmonary bypass .
 Cannulation of:
 Ascending aorta
 Right atrium
 Femoral artery

o Cold potassium cardioplegia .
o
o
o
o
Bypass of arteries by making Incision
in the target artery .
Anastamosis of graft with artery .
On completion of the vascular
anastomoses, the aorta is unclamped.
anticoagulation is reversed by giving
protamine.
Advantages
 Relief of angina in 90% of
patients
 80% angina free after 5 years
 Survival about 95% after 1 year
 Low chance of restenosis
Disadvantages
 2-3 days in ICU, 7-10 day total
hospital stay .
 3-6 month full recovery time .
 5-10% have post-op complications .
 High cost .
Thank you !