Assessment and management of patient with coronary artery disease . Ammar al-alola meshari al-shayie Nader al-mutairi

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Assessment and management of patient with
coronary artery disease .Ammar
al-alolameshari al-shayieNader al-mutairi
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Blood supply of the heart .

• Tow coronary arteries arise from the aortic
  sinuses
• The right coronary artery .
• The left main coronary artery .

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• 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 .

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• 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.

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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 .

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Risk factors

• Uncontrollable
• gender
• Hereditary
• Race
• Age

• controllable
• hypertension
• Diabetes
• hyperlipidemia
• Smoking
• Physical activity
• Obesity
• Stress and anger

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Presentation of patient with CAD

• Asymptomatic (silent CAD).
• Stable angina .
• Unstable angina .
• Myocardial infarction .

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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 .

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Stable angina

• Coronary ischemia is due to imbalance between
  blood supply and oxygen demand .
• It occurs when oxygen demand exceeds blood supply
  .

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Clinical features

• Chest pain or substernal pressure lasts less than
  10-15 minutes .
• brought on by exertion or stress .
• relived by rest or nitroglycerin .

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Diagnosis

• Stress tests .
• Stress ECG recording ECG before, during, and
  after exercise on a treadmill . Positive findings
  include ST segment depression, chest pain,
  hypotension or ventricular arrhythmias .
• Stress ECHO performed before and immediately
  after exercise . It is positive if there is wall
  motion abnormality not present at rest .
• 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 .

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• 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 .

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Treatment

• Risk factor modification
• Quit smoking .
• Control hypertension .
• Control diabetes .
• Control hyperlipidemia .
• Weight loss and exercise .
• Reduce intake of saturated fat and cholesterol .

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• Medical therapy .
• Aspirin.
• Beta blockers .
• Nitrates .
• Calcium channel blockers .
• ACE inhibitors and diuretics if heart failure
  present .

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• Revascularization .
• Percutaneous coronary intervention (PCI) .
• Coronary artery bypass grafting (CABG) .

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Unstable angina

• Blood supply is decreased secondary to reduced
  resting coronary flow .
• In contrast to stable angina , oxygen demand is
  unchanged .

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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 .

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Diagnosis

• History .
• Stress tests .
• Cardiac catheterization with coronary
  arteriography .
• Diagnostic workup to exclude myocardial
  infarction .

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Treatment

• Hospital admission
• Medical therapy
• Oxygen
• Morphine
• Nitrates
• Aspirin
• Beta blockers
• Catheterization/Revascularization .

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• After the acute treatment
• Continue aspirin, beta blockers and nitrates .
• reduce the risk factors .

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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 .

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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 .

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Diagnosis

• ECG .
• Cardiac enzymes ( CK-MB and Tropnins ).

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Treatment

• Admission to the CCU .
• Medical therapy
• Oxygen
• Morphine
• Nitrates
• Aspirin
• Beta blockers
• ACE inhibitors
• Statins
• Heparin

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• Revascularization .
• Benefit is highest if performed early .
• Should be considered in all patients .
• Two forms of revascularization thrombolysis or
  PCI .

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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.

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• 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.

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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 .

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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.

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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.

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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.

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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.

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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.

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• Most common arteries bypassed
• Right coronary artery
• Left anterior descending coronary artery
• Circumflex coronary artery

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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 .

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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

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• Cold potassium cardioplegia .
• 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.

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Advantages

• Relief of angina in 90 of patients
• 80 angina free after 5 years
• Survival about 95 after 1 year
• Low chance of restenosis

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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 .

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• Thank you !