Coronary Artery Disease: Diagnosis and Treatment

1. Northwestern Memorial HospitalHealthy Transitions Fall ProgramOctober 7, 2013 Coronary Artery Disease: Diagnosis and Treatment Mark J. Ricciardi, MD Director, Interventional Cardiology and Cardiac Catheterization Northwestern Bluhm Cardiovascular Institute

2. Outline • Coronary artery disease (CAD) basics • Diagnosis of CAD • Cardiac Catheterization / Coronary Angiography • Treatment of CAD • Coronary Angioplasty / Stent • Past, present, future

3. Coronary Disease • Atherosclerosis • ‘Arteriosclerosis’ • Fatty buildup in lining of artery wall • Plaque • Impinges on flow • Reduces amount of blood and oxygen delivered to the heart muscle

4. Cholesterol deposition

5. Early CAD

7. Coronary Thrombosis“Heart Attack”

8. CADthe goal… • is prevention • Primary prevention • Prevent early / sub-clinical stages • Heart healthy lifestyle • Starting in childhood • Medications • Targeted at high risk groups

9. Diagnosis of CAD • History • Symptoms • Angina

10. Diagnosis of CAD • History • Symptoms • Angina • Non-invasive imaging • Stress testing • provocation • CT angiogram • good, not great

11. Diagnosis of CAD • History • Symptoms • Angina • Non-invasive imaging • Stress testing • CT angiogram • Invasive imaging • Left heart catheterization / coronary angiography … the gold standard for Dx

12. Coronary AngiographyPurposes • Define coronary anatomy, and presence, absence, degree obstruction • Most commonly used to: • determine extent of CAD • assess feasibility and appropriateness of mechanical revascularization

13. Catheterization

14. Catheterization

15. Coronary Angiography

16. Coronary Angiography

17. Arterial access Femoral artery Most common access site since 1980s Easy and reliable Often requires 20-30 minutes of pressure to prevent bleeding - followed by bed-rest 1% risk significant bleeding There are new strategies that hasten recovery time Bleeding still an issue

18. Arterial access Radial artery Lower risk of significant bleeding No bed rest required

19. Arterial access Radial artery

20. Arterial access Radial artery “Down side” -the learning curve

21. CAD Treatment

22. CAD TreatmentThe past…

23. CAD Treatment • Secondary prevention • Lifestyle modification • Diet, exercise, tobacco cessation • Rx underlying risk factors • Aspirin and ‘statin’ medications • Anti-anginal medications • Beta blockers

24. Coronary Bypass

25. Coronary Angioplasty

26. Coronary Angioplasty

27. Coronary Stenting

28. Coronary Stenting

29. Drug Stents

30. Northwestern Memorial Hospital Cardiac Catheterization Center • Chicagoland’s First: • Coronary Stent (1990s) • Drug eluting stent (early 2000s)

31. Northwestern Memorial Hospital Cardiac Catheterization Center • Chicagoland’s First: • Coronary Stent (1990s) • Drug eluting stent (early 2000s) • Bio-absorbable stent (2013)

32. Next Generation Stents Bioabsorbable / dissolving stents In clinical trials at Northwestern

33. Conclusions • CAD • Sub-clinical plaque formation • Symptomatic CAD • Angina, heart attack • Non-invasive and invasive testing • CAD Treatment • Behavioral, pharmacologic, mechanical • NW big part of the past, present and future of CAD Rx

34. Questions? • http://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=angiog • http://www.scai.org/PatientEducation/default.aspx

36. Judkins Technique JL and JR catheters Melvin Judkins

37. CineangiographyAngiographic views

38. Femoral Artery Hemostasis Perclose Suture-Mediated Closure System (Abbott Vascular) • Non-braided polyester suture • Automated knot tying • Closure of 5-8Fr. access sites • ‘pre-closure’

39. Transradial Angiography / InterventionAnatomy No associated major nerve Median N in carpal tunnel Ulnar N runs with UA Dual arterial supply to hand RA and UA join in 2 arches Superficial and deep palmar arches

40. Radial Artery Compression Devices

42. Femoral Radial The most important bleeding avoidance strategy?