Assessment and management of patient with coronary artery
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Transcript 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 !