management of ihd

Management of IHD

Prepared by:Mohd Faizal Nizam bin Mohd

Fozi

Contents

• General measures• Medically • Surgically ;

– Percutaneous coronary intervention (PCI):– Types – Surgical indications– Method– complications

– CABG

Medical intervention• Thrombolytic Agents (streptokinase, tPA)• Oral anti-platelet agents;

– Cyclo-oxygenase inhibitors (ASA, clopidogrel, ticlopidine)

– Anticoagulants (unfractionated heparin, LMWH)• Anti ischemic agents

– Nitrates– Morphine– Beta blockers– Calcium antagonist

• Statins

Surgical intervention

• Percutaneous coronary intervention (PCI)– techniques of capable of relieving coronary

narrowing– More effective than thrombolytic therapy– Less invasive alternative to coronary artery

bypass surgery

Types of PCI• Balloon tipped angioplasty with and without stent• Coronary artherectomy – three methods

– Directional coronary artherectomy (DCA)– shaves plaque into catheter tip

– Coronary rotational ablasion (Rotablator) – high speed rotating shaver to grind up plaque

– Transluminal extraction catheter (TEC) – cutting head shaves plaque and suctions out the pieces

• EXCIMER laser coronary atherectomy (ELCA) – laser vaporizes atheroma

• Implantation of stent

Copyright ©2003 BMJ Publishing Group Ltd.

Grech, E. D BMJ 2003;326:1137-1140

Equipment commonly used in percutaneous coronary interventions

Surgical indication• Asymptomatic/mild angina

• left main stenosis• left main equivalent (proximal LAD/proximal

circumflex)• Triple vessel disease

American College of Cardiology (ACC) and American Heart Association (AHA)

• Stable angina• Left main stenosis• Left main equivalent• Triple vessel disease• 2 vessel disease with proximal LAD stenosis and EF <

50% @ demonstrable ischemia• 1 @ 2 vessel disease without proximal LAD stenosis but

with a large territory at risk and high risk criteria on noninvasive testing

• Disabling angina refractory to medical therapy


• Unstable angina/NSTEMI

• Left main• Left main equivalent• Ongoing ischemia not responding to maximal

nonsurgical therapy


• ST elevation MI

• Failed PCI with persistent pain or hemodinamic instability and anatomical feasible

• Persistent or recurrent ischemia refractory to medical treatment with acceptable anatomy who have a significant territory at risk and not a candidate for PCI

• Requires surgical repair of postinfarction ventricular septal rupture or mitral valve insufficiency

• Life threatening VA in the presence of > 50% left main stenosis @ triple disease


• Poor LV function• Left main stenosis• Left main equivalent• Proximal LAD stenosis and 2 to 3 triple disease

• Life threatening VA• Left main disease• 3 vessel disease


• Failed PCI• Ongoing ischemia with significant territory at risk• Hemodynamic instability

• Previous CABG• Disabling angina refractory to medical therapy• Non patent previous bypass grafts, but with class I

indication for native CAD.


Clinical indications for percutaneous coronary intervention (PCI)

• Stable angina (and positive stress test)• Unstable angina• Acute myocardial infarction• After myocardial infarction• After coronary artery bypass surgery (percutaneous

intervention to native vessels, arterial or venous conduits)• High risk bypass surgery• Elderly patient

British Medical Journal

PCI

• Catheter threaded through artery – usually femoral or radial to the aortic root

• Guide wire is then inserted into the coronary artery and advanced past the area of stenosis

PCI• Balloon tipped

catheter inserted over guide wire until balloon is in area of stenosis

• Balloon is inflated pushing plaque against the vessel wall

PCI

• Most PCI are performed with the use of stents

• Wire mesh coil pushed against vessel wall to prevent closure of the vessel post procedure

PCI

• Presence of a foreign object in the vessel can induce clot formation and therefore restenosis

• Development of drug eluding stents has reduced this risk

Complications

• Major complications are uncommon• death (0.2% but higher in high risk cases)• acute myocardial infarction (1%) which may

require emergency coronary artery bypass surgery

• embolic stroke (0.5%)• cardiac tamponade (0.5%)• systemic bleeding (0.5%).

British Medical Journal

References • Surgical Management of Myocardial Ischemia,

Prof Hafil Budianto Abdulgani, BA, MD, PhD, FACS, FACC.

• British Medical Journal, Percutaneous coronary intervention. II: The procedure, Ever D Grech, consultant cardiologist, assistant professor, Health Sciences Centre and St Boniface Hospital, Winnipeg, Manitoba, Canada, University of Manitoba, Winnipeg.

• American College of Cardiology (ACC) / American Heart Association (AHA) GUIDELINES

management of ihd

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