Management of Coronary Artery Disease

2. Management of Coronary Artery Disease • Primary Prevention • Risk factor modification • Life style changes • Cholesterol medications – Dr. Woodruff • Management of disease • Secondary Prevention • Medications that decrease future events • Aspirin, beta blockers, statins • Medications that improve cardiac hemodynamics • Ace Inhibitors – Dr. Jeffries, Dr. Hunter

3. Management of Coronary Artery Disease • Management of Disease (continued) • Medications that improve myocardial oxygen supply and demand • Nitrates, beta blockers, calcium channel blockers, Dr. Abel, Dr. Lynch • Myocardial Revascularization • Medications • Thrombolytics, Platelet Inhibitors • Surgical Management • Percutaneous Management

4. Myocardial Revascularization • Medications • Antiplatelet Agents • Oral • Aspirin, Clopidrogel, Ticlopidine • IV Antiplatelet Agents • Glycoprotein IIb/IIIa agents • Antithrombotic Agents • Unfractionated Heparin • Low Molecular Weight Heparin • Direct Thrombin Inhibitors

5. Myocardial Revascularization • Medications • Thrombolytic Agents • Streptokinase • t-PA • Tenecteplase, reteplase • Coronary Artery Bypass Surgery (CABG) – Dr. Sugimoto • Percutaneous Coronary Intervention (PCI)

6. Myocardial Revascularization • Percutaneous Coronary Intervention • Balloon Angioplasty • Stent Placement • Atherectomy • Radiation Therapy

7. Cardiac Catheterization

8. Cardiac Catheterization

9. Coronary Intervention

10. Coronary Intervention

11. Management of Coronary Artery Disease • So how do we decide which method of Myocardial Revascularization? • Medications • Surgical Management • Percutaneous Management

12. Principle # 1 of Myocardial Revascularization • There are three broad indications for myocardial revascularization in coronary artery disease • To treat the symptoms of angina pectoris • To improve long term survival • To prevent nonfatal events such as nonfatal myocardial infarction, congestive heart failure, or serious ventricular arrhythmias

13. Principle #2 of Myocardial Revascularization Stable Angina

14. Stable Coronary Syndromes • Unstable Coronary Syndromes • Unstable Angina • Myocardial Infarction

15. Stable Coronary Syndromes • Blood vessel with atherosclerotic plaque Endothelium Smooth muscle cells Fibrous cap Plaque //A&P/241.a.1

16. Management of Stable Coronary Artery Disease • Medical Therapy • Aspirin, Calcium Channel Blockers, Beta Blockers, Nitrates • Little role for antithrombotic agents, IV glycoprotein IIb/IIIa agents, thrombolytics • Myocardial Revascularization • Percutaneous Coronary Intervention • Coronary Artery Bypass Surgery • Which do we choose?

17. Coronary Artery Bypass Surgery • CABG 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 • Relief of Symptoms • Any patient that is unresponsive to medical therapy or percutaneous intervention

18. Myocardial Revascularization • CABG 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

19. Myocardial Revascularization

20. Coronary Intervention

21. Percutaneous Coronary Intervention vs. Medical Therapy • Patients treated with PTCA achieve greater symptomatic benefit than medically treated patients, particularly those patients with the most severe baseline angina • Over time this benefit is not as great • No study has ever documented a benefit from coronary revascularization compared with medical therapy on survival or infarction

24. Management of Coronary Artery Disease • 1. Stable Coronary Syndromes • 2. Unstable Coronary Syndromes • a. Unstable Angina • b. Myocardial Infarction

26. Unstable Angina

27. Management of Unstable Coronary Artery Disease • Medical Therapy • Aspirin, Calcium Channel Blockers, Beta Blockers, Nitrates • Much more important role for antithrombotic agents, IV glycoprotein IIb/IIIa agents, thrombolytics • Myocardial Revascularization • Percutaneous Coronary Intervention • Coronary Artery Bypass Surgery • Which do we choose?

28. Medical Management of Unstable Angina • Thrombus formation plays an important role • Involves platelet aggregation • Involves thrombus formation

29. Medical Management of Unstable Angina Aspirin – decreases platelet aggregation

30. 2 AT Thrombin 1 Pentasaccharide sequence Medical Management of Unstable Angina Heparin – decreases thrombus formation Heparin

31. Medical Management of Unstable Angina Low Molecular Weight Heparin

32. Medical Management of Unstable Angina Glycoprotein IIb/IIIa Agents

33. Medical Management of Unstable Angina • Could there be a beneficial effect of thrombolytic therapy in patients with non-occlusive thrombus? • Studies actually demonstrate a higher mortality with thrombolytic therapy compared to placebo • Thrombolysis is known to activate platelets which can lead to progression of the thrombus to total occlusion and MI

34. Coronary Revascularization • Surgical and Percutaneous revascularizations for Unstable Angina follow the same general guidelines, i. e. • Surgery for Left Main, and 3 vessel CAD (especially with proximal LAD involvement, or impaired LV function

35. Percutaneous Coronary Intervention

38. Acute ST-Elevation MI • Over 1.5 million patients suffer an acute ST-elevation MI in the U.S. each year • ST-elevation MI is still the leading cause of mortality in the U.S. —over 500,000 deaths each year • 200,000 of all ST-elevation MI patients receive fibrinolytic therapy • 5-6% of patients receiving fibrinolytic therapy die within 30 days • 1% of patients receiving fibrinolytic therapy experience an intracranial hemorrhage during hospitalization

40. Management of Acute Myocardial Infarction • Primary Goal is to OPEN THE ARTERY • Why? Time is muscle and muscle is life

41. Management of Acute Myocardial Infarction • Thrombolytic Therapy • Percutaneous Intervention

42. Goals of Fibrinolytic Therapy • Break-up fibrin mesh that stabilizes the clot • Allow normal hemostatic processes to break down remaining clot • Restore normal blood flow (TIMI 3 blood flow) through the coronary artery

43. Medications • Thrombolytic Agents • Streptokinase • t-PA • Tenecteplase, reteplase

44. Mechanism of Action of Fibrinolytic Therapy Indirect fibrin degradation Plasminogen Fibrinolytic Plasmin

45. Thrombolytic Therapy

46. Thrombolytic Therapy

47. Thrombolytic Therapy

48. Thrombolytic Therapy

49. Management of Acute Myocardial Infarction What Role other antiplatelet and antithrombotic agents? • Aspirin in all patients not allergic, clopidrogel in those that are • Heparin (antithrombotics) in those patients receiving selective thrombolytic therapy or those that are at high risk for systemic emboli (large or anterior MI, atrial fibrillation, etc.) • Glycoprotein IIb/IIIa agents have no role currently in patients receiving thrombolytic agents, but are beneficial in patients treated with mechanical reperfusion (PCI)

50. Management of Acute Myocardial Infarction - PCI