Management of Coronary Artery Disease Primary Prevention –Risk factor modification Life style...

Management of Coronary Artery Management of Coronary Artery DiseaseDisease

Primary PreventionPrimary Prevention– Risk factor modificationRisk factor modification

Life style changesLife style changes Cholesterol medications – Dr. WoodruffCholesterol medications – Dr. Woodruff

Management of diseaseManagement of disease– Secondary PreventionSecondary Prevention– Medications that decrease future eventsMedications that decrease future events

Aspirin, beta blockers, statinsAspirin, beta blockers, statins

– Medications that improve cardiac hemodynamicsMedications that improve cardiac hemodynamics Ace Inhibitors – Dr. Jeffries, Dr. HunterAce Inhibitors – Dr. Jeffries, Dr. Hunter


Management of Disease (continued)Management of Disease (continued)– Medications that improve myocardial oxygen Medications that improve myocardial oxygen

supply and demandsupply and demand Nitrates, beta blockers, calcium channel blockers, Dr. Nitrates, beta blockers, calcium channel blockers, Dr.

Abel, Dr. LynchAbel, Dr. Lynch

– Myocardial RevascularizationMyocardial Revascularization MedicationsMedications

– Thrombolytics, Platelet InhibitorsThrombolytics, Platelet Inhibitors Surgical ManagementSurgical Management Percutaneous ManagementPercutaneous Management

Myocardial RevascularizationMyocardial Revascularization

MedicationsMedications– Antiplatelet AgentsAntiplatelet Agents

OralOral– Aspirin, Clopidrogel, TiclopidineAspirin, Clopidrogel, Ticlopidine

IV Antiplatelet AgentsIV Antiplatelet Agents– Glycoprotein IIb/IIIa agentsGlycoprotein IIb/IIIa agents

– Antithrombotic AgentsAntithrombotic Agents Unfractionated HeparinUnfractionated Heparin Low Molecular Weight HeparinLow Molecular Weight Heparin Direct Thrombin InhibitorsDirect Thrombin Inhibitors


MedicationsMedications– Thrombolytic AgentsThrombolytic Agents

StreptokinaseStreptokinase t-PAt-PA Tenecteplase, reteplaseTenecteplase, reteplase

Coronary Artery Bypass Surgery (CABG) – Coronary Artery Bypass Surgery (CABG) – Dr. SugimotoDr. Sugimoto

Percutaneous Coronary Intervention (PCI)Percutaneous Coronary Intervention (PCI)

Percutaneous Coronary InterventionPercutaneous Coronary Intervention– Balloon AngioplastyBalloon Angioplasty– Stent PlacementStent Placement– AtherectomyAtherectomy– Radiation TherapyRadiation Therapy


Cardiac CatheterizationCardiac Catheterization

Coronary InterventionCoronary Intervention


So how do we decide which method of So how do we decide which method of Myocardial Revascularization?Myocardial Revascularization?– MedicationsMedications– Surgical ManagementSurgical Management– Percutaneous ManagementPercutaneous Management

Principle # 1 Principle # 1 of Myocardial Revascularizationof Myocardial Revascularization

There are three broad indications for There are three broad indications for myocardial revascularization in coronary myocardial revascularization in coronary artery diseaseartery disease– To treat the symptoms of angina pectorisTo treat the symptoms of angina pectoris– To improve long term survivalTo improve long term survival– To prevent nonfatal events such as nonfatal To prevent nonfatal events such as nonfatal

myocardial infarction, congestive heart failure, myocardial infarction, congestive heart failure, or serious ventricular arrhythmiasor serious ventricular arrhythmias

Principle #2 Principle #2 of Myocardial Revascularizationof Myocardial Revascularization

Stable Angina

1. Stable Coronary Syndromes2. Unstable Coronary Syndromes

1. Unstable Angina2. Myocardial Infarction

Stable Coronary SyndromesStable Coronary Syndromes

Blood vessel with atherosclerotic Blood vessel with atherosclerotic plaqueplaque

Endothelium

Smooth muscle cellsFibrous cap

Plaque

//A&P/241.a.1

Management of Stable Coronary Management of Stable Coronary Artery DiseaseArtery Disease

Medical TherapyMedical Therapy– Aspirin, Calcium Channel Blockers, Beta Aspirin, Calcium Channel Blockers, Beta

Blockers, NitratesBlockers, Nitrates– Little role for antithrombotic agents, IV Little role for antithrombotic agents, IV

glycoprotein IIb/IIIa agents, thrombolyticsglycoprotein IIb/IIIa agents, thrombolytics Myocardial RevascularizationMyocardial Revascularization

– Percutaneous Coronary InterventionPercutaneous Coronary Intervention– Coronary Artery Bypass SurgeryCoronary Artery Bypass Surgery

Which do we choose?Which do we choose?

Coronary Artery Bypass SurgeryCoronary Artery Bypass Surgery

CABG vs. Medical TherapyCABG vs. Medical Therapy– Left Main Coronary Artery Left Main Coronary Artery

DiseaseDisease– Patients with 3 vessel coronary Patients with 3 vessel coronary

artery disease especially with artery disease especially with impaired left ventricular function, impaired left ventricular function, LAD involvement, or severe LAD involvement, or severe myocardial ischemiamyocardial ischemia

Relief of SymptomsRelief of Symptoms– Any patient that is unresponsive Any patient that is unresponsive

to medical therapy or to medical therapy or percutaneous interventionpercutaneous intervention

Myocardial RevascularizationMyocardial RevascularizationCABG vs. Medical Therapy

Left Main Coronary Artery Disease

Patients with 3 vessel coronary artery disease especially with impaired left ventricular function, LAD involvement, or severe myocardial ischemia

Coronary InterventionCoronary Intervention

Percutaneous Coronary Intervention Percutaneous Coronary Intervention vs. Medical Therapyvs. Medical Therapy

Patients treated with PTCA achieve greater Patients treated with PTCA achieve greater symptomatic benefit than medically treated symptomatic benefit than medically treated patients, particularly those patients with the most patients, particularly those patients with the most severe baseline anginasevere baseline angina

Over time this benefit is not as greatOver time this benefit is not as great No study has ever documented a benefit from No study has ever documented a benefit from

coronary revascularization compared with medical coronary revascularization compared with medical therapy on survival or infarctiontherapy on survival or infarction


1. Stable Coronary Syndromes2. Unstable Coronary Syndromes

a. Unstable Anginab. Myocardial Infarction

Unstable AnginaUnstable Angina

Management of Unstable Coronary Management of Unstable Coronary Artery DiseaseArtery Disease

Medical TherapyMedical Therapy– Aspirin, Calcium Channel Blockers, Beta Blockers, Aspirin, Calcium Channel Blockers, Beta Blockers,

NitratesNitrates– Much more important role for antithrombotic agents, Much more important role for antithrombotic agents,

IV glycoprotein IIb/IIIa agents, thrombolyticsIV glycoprotein IIb/IIIa agents, thrombolytics

Myocardial RevascularizationMyocardial Revascularization– Percutaneous Coronary InterventionPercutaneous Coronary Intervention– Coronary Artery Bypass SurgeryCoronary Artery Bypass Surgery

Which do we choose?Which do we choose?

Medical Management of Unstable Medical Management of Unstable AnginaAngina

Thrombus formation plays an important roleThrombus formation plays an important role– Involves platelet aggregationInvolves platelet aggregation– Involves thrombus formationInvolves thrombus formation


Aspirin – decreases platelet aggregation


Heparin – decreases thrombusformation

ATHeparin

Pentasaccharide sequence

2

1

Thrombin


Low Molecular Weight Heparin


Glycoprotein IIb/IIIa Agents


Could there be a beneficial effect of Could there be a beneficial effect of thrombolytic therapy in patients with non-thrombolytic therapy in patients with non-occlusive thrombus?occlusive thrombus?

Studies actually demonstrate a higher Studies actually demonstrate a higher mortality with thrombolytic therapy mortality with thrombolytic therapy compared to placebocompared to placebo

Thrombolysis is known to activate platelets Thrombolysis is known to activate platelets which can lead to progression of the which can lead to progression of the thrombus to total occlusion and MIthrombus to total occlusion and MI

Coronary RevascularizationCoronary Revascularization

Surgical and Percutaneous Surgical and Percutaneous revascularizations for Unstable Angina revascularizations for Unstable Angina follow the same general guidelines, i. e.follow the same general guidelines, i. e.– Surgery for Left Main, and 3 vessel CAD Surgery for Left Main, and 3 vessel CAD

(especially with proximal LAD involvement, or (especially with proximal LAD involvement, or impaired LV functionimpaired LV function

Percutaneous Coronary InterventionPercutaneous Coronary Intervention

Acute ST-Elevation MIAcute ST-Elevation MIAcute ST-Elevation MIAcute ST-Elevation MI Over 1.5 million patients suffer an acute ST-elevation Over 1.5 million patients suffer an acute ST-elevation

MI in the U.S. each yearMI in the U.S. each year

ST-elevation MI is still the leading cause of mortality in ST-elevation MI is still the leading cause of mortality in the U.S. —over 500,000 deaths each yearthe U.S. —over 500,000 deaths each year

200,000 of all ST-elevation MI patients receive 200,000 of all ST-elevation MI patients receive fibrinolytic therapyfibrinolytic therapy

5-6% of patients receiving fibrinolytic therapy die within 5-6% of patients receiving fibrinolytic therapy die within 30 days30 days

1% of patients receiving fibrinolytic therapy experience 1% of patients receiving fibrinolytic therapy experience an intracranial hemorrhage during hospitalizationan intracranial hemorrhage during hospitalization

Management of Acute Myocardial Management of Acute Myocardial InfarctionInfarction

Primary Goal is to OPEN THE ARTERY Primary Goal is to OPEN THE ARTERY Why? Time is muscle and muscle is lifeWhy? Time is muscle and muscle is life


Thrombolytic TherapyThrombolytic Therapy

Percutaneous InterventionPercutaneous Intervention

Goals of Fibrinolytic Goals of Fibrinolytic TherapyTherapy

Goals of Fibrinolytic Goals of Fibrinolytic TherapyTherapy

Break-up fibrin mesh that stabilizes the clotBreak-up fibrin mesh that stabilizes the clot

Allow normal hemostatic processes to Allow normal hemostatic processes to break down remaining clotbreak down remaining clot

Restore normal blood flow (TIMI 3 blood Restore normal blood flow (TIMI 3 blood flow) through the coronary arteryflow) through the coronary artery

MedicationsMedications– Thrombolytic AgentsThrombolytic Agents

StreptokinaseStreptokinase t-PAt-PA Tenecteplase, reteplaseTenecteplase, reteplase

Mechanism of Action of Mechanism of Action of Fibrinolytic TherapyFibrinolytic Therapy

Mechanism of Action of Mechanism of Action of Fibrinolytic TherapyFibrinolytic TherapyIndirect fibrin degradationIndirect fibrin degradation

Plasminogen

Plasmin

Fibrinolytic

Thrombolytic TherapyThrombolytic Therapy

Management of Acute Myocardial Infarction Management of Acute Myocardial Infarction What Role other antiplatelet and What Role other antiplatelet and

antithrombotic agents?antithrombotic agents?

AspirinAspirin in all patients not allergic, clopidrogel in in all patients not allergic, clopidrogel in those that arethose that are

HeparinHeparin (antithrombotics) in those patients (antithrombotics) in those patients receiving selective thrombolytic therapy or those receiving selective thrombolytic therapy or those that are at high risk for systemic emboli (large or that are at high risk for systemic emboli (large or anterior MI, atrial fibrillation, etc.)anterior MI, atrial fibrillation, etc.)

Glycoprotein IIb/IIIa agents have no role Glycoprotein IIb/IIIa agents have no role currently in patients receiving thrombolytic currently in patients receiving thrombolytic agents, but are beneficial in patients treated with agents, but are beneficial in patients treated with mechanical reperfusion (PCI)mechanical reperfusion (PCI)

Management of Acute Myocardial Management of Acute Myocardial Infarction - PCIInfarction - PCI

A System of Medicine, 1899 A System of Medicine, 1899

Angina PectorisAngina Pectoris

Treatment: When first called to a patient in the midst Treatment: When first called to a patient in the midst of a paroxysm there is no time for careful of a paroxysm there is no time for careful observation…(it) urges upon us the immediate use observation…(it) urges upon us the immediate use of the vascular antispasmotics. Five to twenty of the vascular antispasmotics. Five to twenty minims of nitrite of amyl may be inhaled. If such minims of nitrite of amyl may be inhaled. If such means are not at hand some very hot water with a means are not at hand some very hot water with a little peppermint essence or brandy may be sipped little peppermint essence or brandy may be sipped slowly….slowly….

Osler’s Principles and Practice of Osler’s Principles and Practice of Medicine, 1938Medicine, 1938

Coronary Artery OcclusionCoronary Artery OcclusionTreatment: Absolute rest is essential. Except in the Treatment: Absolute rest is essential. Except in the

mildest cases complete bed rest for six weeks mildest cases complete bed rest for six weeks should be planned from the outset. Every effort should be planned from the outset. Every effort should be made to reduce anxiety and sources of should be made to reduce anxiety and sources of irritation. Factors which induce an attack should irritation. Factors which induce an attack should be avoided. The diet should be simple, and the be avoided. The diet should be simple, and the bowels kept open mildly. Oxygen is often bowels kept open mildly. Oxygen is often helpful…Nitroglycerine tablets under the tongue helpful…Nitroglycerine tablets under the tongue may give relief of the pain. If pain is severe may give relief of the pain. If pain is severe morphia should be given hypodermically…morphia should be given hypodermically…

The Principles and Practice of The Principles and Practice of Medicine (Harvey, 1980)Medicine (Harvey, 1980)

When a patient is admitted to the frightening environment of a When a patient is admitted to the frightening environment of a CCU, his physician must explain in detail the nature of the CCU, his physician must explain in detail the nature of the illness and the need for cardiac monitoring. Morphine illness and the need for cardiac monitoring. Morphine remains the drug of choice for relief of pain…Oxygen remains the drug of choice for relief of pain…Oxygen administration is a routine measure. During the first 24 – administration is a routine measure. During the first 24 – 48 hours the patient should be kept at bed rest. After the 48 hours the patient should be kept at bed rest. After the first 24 – 48 hours uncomplicated patients may be allowed first 24 – 48 hours uncomplicated patients may be allowed chair rest. Anticoagulants (heparin and coumadin) are chair rest. Anticoagulants (heparin and coumadin) are necessary to prevent venous thrombi of the legs…necessary to prevent venous thrombi of the legs…Lidocaine is initiated when premature ventricular beats Lidocaine is initiated when premature ventricular beats occur with a frequency of six or more per minute…occur with a frequency of six or more per minute…discharge should be at 10 days to 2 weeks.discharge should be at 10 days to 2 weeks.


Primary PreventionPrimary Prevention– Risk factor modificationRisk factor modification

Life style changesLife style changes Cholesterol medications – Dr. WoodruffCholesterol medications – Dr. Woodruff

Management of diseaseManagement of disease– Secondary PreventionSecondary Prevention– Medications that decrease future eventsMedications that decrease future events

Aspirin, beta blockers, statinsAspirin, beta blockers, statins

– Medications that improve cardiac hemodynamicsMedications that improve cardiac hemodynamics Ace Inhibitors – Dr. Jeffries, Dr. HunterMyocardial RevascularizationAce Inhibitors – Dr. Jeffries, Dr. HunterMyocardial Revascularization

MedicationsMedications– Antiplatelet AgentsAntiplatelet Agents

OralOral– Aspirin, Clopidrogel, TiclopidineAspirin, Clopidrogel, Ticlopidine

IV Antiplatelet AgentsIV Antiplatelet Agents– Glycoprotein IIb/IIIa agentsGlycoprotein IIb/IIIa agents

– Antithrombotic AgentsAntithrombotic Agents Unfractionated HeparinUnfractionated Heparin Low Molecular Weight HeparinLow Molecular Weight Heparin Direct Thrombin InhibitorsDirect Thrombin Inhibitors

Management of Coronary Artery Disease Primary Prevention –Risk factor modification Life style...

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