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CORONARY ARTERYDISEASE

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Coronary Artery Disease

Definition:CAD is a term that refers to the effect of theaccumulation of atherosclerosis plaque in thecoronary arteries that obstructs blood flow to the

myocardium

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Cont.

Conditions result from CAD

1. Angina Pectoris

2. 2. Myocardial Infarction

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Angina Pectoris

Definition:

Angina pectoris, is the medical term usedto describe acute chest pain ordiscomfort.

Angina occurs when the hearts need foroxygen increases beyond the level ofoxygen available from the blood nourishingthe heart.

It has 3 types

Stable Angina Un stable angina & Variant Angina (Prinzmetals or resting

angina) :

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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

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Clinical Manifestations

Characteristics: Squeezing, burning, pressing,choking, or bursting pressure.

Onset: Quickly or slowly

Location: Chest, right or left arms,shoulder, or neck, jaw.

Duration: Less then 5 minutes.

Associated: Dyspnea, Sweating, faintness,

palpitation, dizziness ect. Relieving: GTN and rest.

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

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Investigations

Electrocardiogram ( ECG)

Coronary angiography

Exercise Electrocardiogram (Stresstest).

Complications: Myocardial infarction

Cardiac Arrhythmias

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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.

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PATHOPHYSIOLOGY

Coronary artery cannot supply enough blood to the heart inresponse 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

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ECG changes in Angina & MI

Zone of Ischemia: T wave inversion

Zone of Injury: ST elevation

Zone of Necrosis: Abnormal Q wave

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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

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Cont

Other symptoms include:

Shortness of breath(SOB)

Weakness andtiredness

Anxiety

Lightheadedness

Dizziness

Nausea vomiting

Sweating, which maybe profuse

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Radiographic Assessment

ECG

Stress Test

Myocardial perfusion imaging

MRI

Cardiac Catheterization

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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 thefibrinolytic processes.

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

Administration is most crucial between 3-6 hours after the initial infarction hasoccurred.

Detect for occult bleeding during and after thrombolytic therapy.

Assess neurologic status changes which may indicate GI bleeding or cardiactamponade.

Anticoagulant and antiplatelet medications are administered afterthrombolytic therapy to maintain arterial patency.

Other Medications:

Beta-adrenergic blocking agents

Diazepam

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Surgical management

PTCA (Percutaneous TransluminalCoronary Angioplasty

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Coronary Artery Bypass Graft

surgery (CABG)

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Coronary

revascularization with coronary

artery bypass

graft (CABG)

surgery is

recommended

for patients who

(1) fail medical

management, (2)

have left maincoronary artery

or three-vessel

disease

Surgical Therapy

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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 anartery 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 ofany 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.

PRE-OPERATIVE

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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 willreceive 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 ofIV fluids & medication. You will have drain tubes and

catheter for

Minimum 2days

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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

INTRA-

OPERATIVE

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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 ExercisesSpirometry

Limb Exercises( Active & Passive ROM , -

Flexion,

Extension, Circumduction)

POST-OPERATIVE

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Early Ambulation:

Sitting at the edge of the bed with feet

dangling (1-2nd day)

Bed side ambulation ( 2nd3rd day)

Pace walking

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Diet:

Low Fat diet

Not more than 12 - 15% of total calories shouldcome from fat.

Plenty of vegetables & fruits ( High Fibre).

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The off-pump coronaryartery 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 cardiopulmonarybypass (CPB).

Surgical Therapy

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Transmyocardial laser revascularization (TMR) is an indirectrevascularization procedure used for patients with advancedCAD who are not candidates for traditional bypass surgeryand who have persistent angina after maximum medicaltherapy.

Surgical Therapy

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PTCA (Percutaneous Transluminal Coronary Angioplasty

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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 atheromatousplaque.

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Stent involves use of rigid but flexible structure that

maintains the integrity of the vascular wall and patency ofthe artery.

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Thank you

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