Coronary Artery Disease: Diagnosis and Treatment Northwestern Memorial Hospital Healthy Transitions Fall Program October 7, 2013 Coronary Artery Disease: Diagnosis and Treatment Mark J. Ricciardi, MD Director, Interventional Cardiology and Cardiac Catheterization Northwestern Bluhm Cardiovascular Institute

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

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

Cholesterol deposition

Early CAD

Vulnerable Plaque Plaque Rupture

Coronary Thrombosis “Heart Attack”

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

Diagnosis of CAD History Symptoms Angina

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

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

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

Catheterization

Catheterization

Coronary Angiography

Coronary Angiography

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

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

Arterial access Radial artery

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

CAD Treatment

CAD Treatment The past…

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

Coronary Bypass

Coronary Angioplasty

Coronary Angioplasty

Coronary Stenting

Coronary Stenting

Drug Stents

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

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

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

Conclusions CAD Symptomatic CAD CAD Treatment 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

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

Judkins Technique JL and JR catheters Melvin Judkins Radiology associate of Charles Dotter at University of Oregon, had studied coronary angiography with Dr. Mason Sones. Went on to create own system of diagnostic imaging, introducing a series of specialized catheters and perfecting transfemoral approach (introducing the catheter via a groin puncture rather than the more complex procedure used by Sones of introducing the catheter via surgical opening of the brachial artery in the arm).  Ptca.org

Cineangiography Angiographic views

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’

Transradial Angiography / Intervention Anatomy 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 #1 you can get to the heart from here. #2 dual supply to hand

Radial Artery Compression Devices

The most important bleeding avoidance strategy? Femoral Radial