Disease of the coronary

arteries
 Outline
• Introduction
• Epidemiology
• Risk factor
• Diagnosis
• Management
 Introduction
• The coronary circulation consists of coronary arteries, the
microcirculation and the coronary veins
• 50% or more reduction in this blood supply to the
myocardium is incompatible with life
• the all-encompassing term ‘coronary heart disease’ includes
both CAD and microvascular dysfunction.
• CAD is more readily identifiable and the most common
underlying pathophysiological process is coronary
atherosclerotic disease
 Anatomy
 LAD: diagonals and
septals
 Cx : obtuse marginals,
occasionally (PDA)
 RCA : acute marginals,
posterior lateral artery
(PLA) and PDA
 Ramus intermedius:
arises between LAD and
CX in 5%-10% of
population
 Anatomy cond’…
Right Dominant Left Dominant
Co-Dominant
 RCA gives rise to the PDA and then ends, while
the CX supplies the PLA branches
 CX may also supply a left PDA that runs
parallel to the right PDA
 Hemodynamics
• Coronary Arteries perfuse in diastole
• Coronary sinus collects used blood from the
myocardium to send to lungs
• Coronary bridging =compression of coronary
artery by the myocardium during systole
 Arteriosclerosis
Disease of the arteries characterized by
thickening, loss of elasticity and calcification of
arterial walls
Resulting in decreased blood supply particularly
to the cerebrum and lower extremities
Often develops with:
• aging
• hypertension
• diabetes
 MORPHOLOGY

Development of Coronary Artery Stenosis

• Focal intimal accumulations of lipids, complex carbohydrates, blood

and blood products, fibrous tissue, and calcium deposits ……
Associated changes in the media

– Chronic, most often progressive, and hence serious, even in

clinically silent periods
– Haemorrhage may occur suddenly within a plaque
– Thrombosis occasionally complicates the process, Acute MI
– Platelet aggregation

• Usually affects multiple coronary arteries

• Usually involves the proximal portion of the larger coronary arteries
• In 10% to 20%, the left main coronary artery is importantly stenotic
Progression of Arteriosclerosis
 Natural history
Schematic illustration, CCS
 Coronary disease cond..
• may manifest as an acute or chronic coronary
syndrome
• The ACS arise from atherosclerotic plaque rupture
with subsequent coronary thrombosis and/or spasm
• ACS may have a spectrum of clinical manifestations
ranging from unstable angina, acute myocardial
infarction, acute pulmonary edema or even sudden
death
• CCS typically manifests as exertional angina
Epidimology
• Distribution of Cardiovascular Diseases
Accounting for Deaths Worldwide
 Risk factors
• High blood pressure (hypertension)
• High blood cholesterol
• Smoking
• Obesity
• Physical inactivity
• Controllable
Diabetes
• Stress (?)
 Risk Factors (cont’d)

• Gender
• Heredity
• Age
Uncontrollable
 Major Risk Factors:
The Big Three
• Hypertension
• High cholesterol All three increase risk
factor eight times
• Cigarette smoking

AND…. we should add LACK OF EXERCISE

• Clinically, AMI has been sub-classified on the basis of the
presenting ECG
• ST-elevation myocardial infarction (STEMI) or Non-ST elevation
myocardial infarction (NSTEMI)
• In STEMI, immediate coronary reperfusion strategies on
arrival to hospital are mandated
• This nomenclature has replaced the previous classification of
Q-wave and non-Q wave MI
• it has been estimated that more than 3 million suffer
from STEMI and 4 million people suffer from NSTEMI
worldwide each year
 Diagnosis
• History
• Physical examination
• Cardiac enzymes
• ECG
• Echocardiography
• Stress test
• Nuclear imaging
• Angiography
 Scenarios

Symptom complex of ECG evidence of a silent

angina pectoris or an acute MI
acute MI

CAD
Cardiomegaly and
symptoms of CHF with A positive ECG response
out any other obvious to a graded exercise test
cause
 Clinical
• Angina pectoris • Traditional clinical
– Precise nature, location, classification of suspected
duration, and severity anginal symptoms
– Precipitating and – Value in determining the
relieving causes likelihood of obstructive CAD
– Any recent changes in
pain pattern
• Chest discomfort
• Dyspnoea
• Fatigue or faintness,
nausea, burning,
• Restlessness, or a sense
of impending doom
• Performance status
 Table Grading of effort angina severity according to the
Canadian Cardiovascular Society
• Widely used as a grading system for angina,
• To quantify the threshold at which symptoms occur in relation to
physical activities
 Physical examination

• Thorough systematic
– Anaemia
– BP
– BMI
• The lungs and heart
– Stigma of ischemic and valvular heart disease
– Cardiac murmurs
– Arrythmia
– Adequacy of presternal soft tissues
– Peripheral pulses, veins
– Neurologic examination
 Comorbidities and other causes of symptoms

• Before any testing is considered, • Hyperlipidaemia

assess the patient’s general health,
comorbidities, and quality of life. • Arterial hypertension
• Diabetes
• If revascularization is unlikely • A history of MI
– Further testing reduced to a
clinically indicated minimum • Smoking
and • A particularly stressful
– Appropriate therapy should be occupation or lifestyle
instituted, a trial of antianginal
medication even if • A history suggesting
– TIA or stroke
• Non-invasive functional imaging – Intermittent
for ischaemia may be an option if claudication
there is need to verify the diagnosis
 Basic testing & Assessment t of LV function
• Biochemical tests
– To identify possible causes of ischaemia,
– To establish cardiovascular risk factors and associated conditions,
and
– To determine prognosis
Resting electrocardiogram and ambulatory monitoring

• Diagnosing myocardial
ischaemia
– Detection of repolarization
abnormalities
• ST-segment depressions
• Indirect signs of CAD
– Previous MI (pathological Q
waves)
– Conduction abnormalities
[mainly (LBBB) impairment of
atrioventricular conduction].
– Atrial fibrillation (AF)
• During ongoing angina
Echocardiography

• A decreased LV function
and/or regional Wall
motion abnormalities
– Increase the
suspicion of
ischaemic
myocardial damage

• A pattern of LV
dysfunction following
the theoretical
distribution territory of
the coronary arteries
– Typical in patients
who have already
had an MI
Chest X-ray
• Does not provide specific
information for diagnosis or
event risk stratification.
• Occasionally in assessing
patients with suspected HF.
• Pulmonary problems
• To rule-out another cause of
chest pain in atypical
presentations.
 Coronary CTA • Figure A-C, MDCTA volume rendering images show significant
(MDCT) stenoses of major coronary arteries (arrows), three-system
disease. These coronary lesions (arrows) were confirmed on
• Preferred test conventional coronary arteriography (D-E),
– A lower range of
clinical likelihood
of CAD,
– No previous
diagnosis of CAD,
and
– Characteristics
with a high
likelihood of good
image quality.
• Detects subclinical
coronary
atherosclerosis,
• Accurately rule out
both anatomically
and functionally
significant CAD
 Invasive testing
CORONARY ANGIOGRAPHY
• Definitive diagnostic procedure, but only necessary
– Inconclusive non-invasive testing
– Non-invasive assessment suggests high event risk for
determination of options for revascularization
– In a patient with a high clinical likelihood of CAD, and
– Symptoms unresponsive to medical therapy or with typical angina
at a low level of exercise

• Detailed assessment from several angles of both coronary

ostia and all major and minor branches
– Remains an imperfect method
• The anatomic distribution and severity of
hemodynamically significant coronary lesions determines,
in large part, the optimal therapy
 Treatment for CHD
• Lifestyle changes
• Medication
• Surgery
 Lifestyle Changes
• Change of habits
• Low fat diet
• Lower weight
• Increase exercise
• Stop smoking
 Medications to Treat CHD
• Beta blockers
• Nitroglycerine and other nitrates
• Calcium-channel blockers
• Aspirin
• Cholesterol-lowering drugs
– lovastatin, colestipol, cholestyramine, etc
• Digitalis
• ACE inhibitors
• Diuretics
 Surgery to Treat CHD
• Balloon angioplasty
• Atherectomy
• Laser angioplasty
• Stent insertion
• Coronary artery bypass operation (CABG)
 CORONARY REVASCULARIZATION

• Overarching goals
– Improve
symptoms
– Prolong survival
– Improved quality
of life

• Techniques
– PCI
– HYBRID REVASC
– CABG
• The standard
by which the
other
techniques
are measured
 CABG WITH CPB

• CABG remains the most common cardiac surgical procedure

• Current surgical practice is largely based on an anatomical definition

of complete revascularization, and aims to bypass

• All epicardial vessels with a diameter exceeding >_1.5

mm and a luminal reduction of >_50% in at least one
angiographic view
 PREOPERATIVE CARE
• Information to pt., counselling and
consenting
• Prophylactic antibiotics
– Cefazolin, cefuroxime
– Clindamycin, vancomycin
• Continue up to the time of operation
– Aspirin
– ß-adrenergic receptor
– calcium channel blockers,
– Statins
• Discontinued preoperatively
– ACE inhibitors,
– Digitalis preparations unless AF
is present
– Platelet anti aggregating, VKA,
NOAC
Figure 1: Central illustration with the main recommendations.; ARB: angiotensin II receptor blocker;
LDL: low-density lipoprotein; : NOACs: nonvitamin K antagonist oral anticoagulants; POAF:
postoperative atrial fibrillation
 CONDUITS SELECTION

• long-term patency of grafts maximized with

the use of arterial grafts, specifically the IMA
• Radial artery
• Great saphenous vein
 OPERATIVE TECHNIQUES
• General anaesthesia, Central lines, TEE
• Position
– Supine with arms tucked at the side
– The lower extremities with a slight external rotation and flexion of
the knees
• Prepared and draped
– The lower neck, the chest, and abdomen between the anterior
axillary lines, and
– The lower extremities circumferentially
• Incisions
– Median sternotomy
• The pericardium divided vertically
• Distal aorta examined and palpated
• Systemic anticoagulation
– Intravenous 300 U/kg of unfractionated heparin
Combinations for Internal Mammary Artery Bypass Grafts