CORONARY ARTERY DISEASE

Coronary Artery Disease

Definition:
CAD is a term that refers to the effect of the accumulation of atherosclerosis plaque in the coronary arteries that obstructs blood flow to the myocardium

Cont.

Conditions result from CAD

Angina Pectoris 2. 2. Myocardial Infarction

1.

Angina Pectoris
Definition:

Angina pectoris, is the medical term used to describe acute chest pain or discomfort. Angina occurs when the hearts need for oxygen increases beyond the level of oxygen available from the blood nourishing the heart. It has 3 types Stable Angina Un stable angina & Variant Angina (Prinzmetals or resting angina) :

Mechanism Of Angina

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Causes

Coronary atherosclerosis (atheroma ) Factors increasing preload : Hyperthyroidism Exercise Anemia Factors increasing after load: Hypertension Aortic stenosis Obstructive cardio myopathy Coronary artery spasm

Clinical Manifestations
Characteristics: Onset:

Squeezing, burning, pressing, choking, or bursting pressure. Quickly or slowly Location: Chest, right or left arms, shoulder, or neck, jaw. Less then 5 minutes. Dyspnea, Sweating, faintness, palpitation, dizziness ect.

Duration: Associated:

Relieving:
Aggravating:

GTN and rest.

exertion, exercise, heavy meal, emotional upset, and anger.

Investigations

Electrocardiogram ( ECG)

Coronary angiography
Exercise Electrocardiogram (Stress test).

Complications:

Myocardial infarction

Cardiac Arrhythmias

Myocardium Infarction

Myo means muscle, Cardiac heart, infarction means death of tissues due to lack of blood supply.

It is also called heart attack. It occurs when coronary arteries become blocked and the part of myocardial muscles become dead due to prolonged lack of oxygen supply to the muscle cells.

PATHOPHYSIOLOGY
Coronary artery cannot supply enough blood to the heart in response to the demand due to CAD Within 10 seconds myocardial cells experience ischemia Ischemic cells cannot get enough oxygen or glucose

Ischemic myocardial cells may have decreased electrical & muscular function
Cells convert to anaerobic metabolism.

Cells produce lactic acid as waste

Pain develops from lactic acid accumulation Pt feels anginal symptoms until receiving demand increase 02 requirements of myocardial cells

ECG changes in Angina & MI

Zone of Ischemia: T wave inversion

Zone of Injury: ST elevation Zone of Necrosis: Abnormal Q wave

Sign and Symptom

Classic symptom of heart attack are chest pain radiating to neck, jaws, back of shoulder, or left arm
The pain can be felt like: Squeezing or heavy pressure A tight band on the chest

An elephant sitting on the chest

Cont

Other symptoms include: Shortness of breath (SOB) Weakness and tiredness Anxiety Lightheadedness Dizziness Nausea vomiting Sweating, which may be profuse

Radiographic Assessment

ECG
Stress Test Myocardial perfusion imaging

MRI
Cardiac Catheterization

Drug therapy
Analgesic for relief of pain, this is a priority. Pain may cause shock. Examples, morphine sulfate, lidocaine, Nitroglycerine IV Thrombolytic Therapy to disintegrate blood clot by activating the fibrinolytic processes.

Ex. Streptokinase, urokinase and tissue plasminogen activator (TPA).

Administration is most crucial between 3-6 hours after the initial infarction has occurred. Detect for occult bleeding during and after thrombolytic therapy. Assess neurologic status changes which may indicate GI bleeding or cardiac tamponade.

Anticoagulant and antiplatelet medications are administered after thrombolytic therapy to maintain arterial patency. Other Medications:

Beta-adrenergic blocking agents Diazepam

Surgical management

PTCA (Percutaneous Transluminal Coronary Angioplasty

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Coronary Artery Bypass Graft surgery (CABG)

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Surgical Therapy
Coronary revascularizatio n with coronary artery bypass graft (CABG) surgery is recommended for patients who (1) fail medical management, (2) have left main coronary artery or three-vessel disease

PRE-OPERATIVE

CABG is performed to restore blood flow to your heart by bypassing coronary (heart) arteries that have been narrowed or blocked by the build-up of plaque. In CABG, a surgeon uses a piece of an artery or vein from another part of your body to reroute blood around the blocked or narrowed portion of your coronary artery or arteries. Your surgeon will perform a physical examination and review your medical history before your procedure. Be sure to bring a list of any medications, dietary supplements, allergies any other problem with anesthesia or herbal supplements that you take with you to your doctor's appointment. You also may undergo several pre-operative imaging tests, in which the arteries that deliver blood to your heart are evaluated. Eg. 2D Echo & CAG The day before your procedure, you will get admitted to complete paperwork, have a blood sample taken, be weighed, and have a chest x-ray. You have to undergo complete body preparation as body bath with antiseptic solution , full body shaving & hair to be shampooed. You will be in fast for 8-10 hours.

Take a shower or bath again on the day of surgery with the anti-septic solution we gave you.

At the hospital, you will change into a gown. You will receive an IV, and when its time to go to the operating room, medications will be given to you as ordered.
As a part of your pre-operative preparation respiratory preparation & post operative exercises will be taught to you by physiotherapist. You & your close relative have to give surgical & anesthesia consent for medico-legal aspects.

Post operatively you will be kept in ICU and on fasting for 24 hrs & nutritional needs will be met by administration of IV fluids & medication. You will have drain tubes and catheter for
Minimum 2days

INTRAOPERATIVE

Half an hour back to your scheduled time you will be shifted to operation theatre along with nursing staff. In OT you will be received in pre-op area & your file will be verified for completion of documentation. As soon as surgical team is ready you will be shifted to the specified OT & you will be on your supine position & you will be anaesthetized.

Midline sternotomy incision will be taken on you

POST-OPERATIVE

ICU Stay: You will have to stay 12-24 hrs post operatively in ICU or as recommended by the Surgeon/Anaesthetist.

Exercise: Deep Breathing exercises Chest Exercises Spirometry Limb Exercises( Active & Passive ROM , Flexion, Extension, Circumduction)

Early Ambulation:

Sitting at the edge of the bed with feet dangling (1-2nd day)
Bed side ambulation ( 2nd 3rd day)

Pace walking

Diet: Low Fat diet Not more than 12 - 15% of total calories should come from fat.

Plenty of vegetables & fruits ( High Fibre).

Surgical Therapy
The off-pump coronary artery bypass (OPCAB) procedure uses full or partial sternotomy to enable access to all coronary vessels. OPCAB is also performed on a beating heart using mechanical stabilizers and without cardiopulmonary bypass (CPB).

Surgical Therapy

Transmyocardial laser revascularization (TMR) is an indirect revascularization procedure used for patients with advanced CAD who are not candidates for traditional bypass surgery and who have persistent angina after maximum medical therapy.

PTCA (Percutaneous Transluminal Coronary Angioplasty

Balloon Angioplasty involves insertion of a special catheter through fluoroscopy into the site of occlusion. The balloon tip of the catheter is inflated to compress and rupture the atheromatous plaque.

Stent involves use of rigid but flexible structure that maintains the integrity of the vascular wall and patency of the artery.

Thank you

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