CASE OF THE WEEK

BY

DR. M. ZARRAR ARIF

PGR CARDIOLOGY

HISTORY

PATIENT DATA

Name: Babar Abbas

Age / Gender : 45 y / Male

MOA : Medical Emergency

DOA : 11-03-2011

Address: 149 F Model Town, Lahore

HISTORY

PRESENTING COMPLAINTS

Chest pain for last 2 hours

HOPI

Patient was in usual state of health when he developed complaints of sudden chest pain, central in location, radiating to left arm and neck, severe in intensity and was associated with sweating. No complaints of nausea, vomiting, palpitations or dyspnoea.

HISTORY

Past History

Patient gives history of admission with chest pain 2 days back for which he was admitted in Ittefaq hospital and he was advised stay for evaluation after an ECG but he was discharged on his request.

No previous history of any other hospital stay, surgical interventions etc

HISTORY

Drug History

Patient has been taking following medications since last 2 days

Asprin 75 mg OD

Clopidogrel 75 mg OD

Atorvastatin 20 mg HS

Metoprolol 25 mg BD

Lisinopril 5 mg HS

No history of drug allergy.

HISTORY

Personal History

Patient has no history of smoking or any other addiction

Occupational History

Patient is a school teacher by profession

Family History

No history of DM, IHD in the family

GPE

A middle aged man sitting in bed well oriented in time place and person with vitals

Pulse : 72 / min, regular, normal character with no radio-radial and no radio-femoral delay.

B.P : 160/100 mm Hg

Temp : 980 F

R/R : 16 / min

-ve for Pallor, clubbing, cyanosis.

JVP not raised.

SYSTEMIC EXAMINATION

Cardio Vascular System

On pre-cordial examination inspection normal, on palpation apex beat in 4th intercostal space with normal character, on auscultation first and second heart sounds normal with no added sound.

Respiratory System

Normal findings on inspection palpation and percussion with normal vesicular breathing bilaterally and no added sounds on auscultation.

SYSTEMIC EXAMINATION

Gastro Intestinal System

Normal findings on inspection with no palpable visceromegally and no area of tenderness on palpation, normal bowel sounds on auscultation.

Central Nervous System

Grossly intact HMF with no motor or sensory loss

Provisional Diagnosis

• Acute Coronary Syndrome

INVESTIGATIONSInvestigation Result

Hb 14.3

B/Urea 30

S/Creatinine 0.9

S/Na+ 138

S/K+ 4

Troponin T (Kit Method) -ve

ECG

ECG findings are as below

It showed regular sinus rhythm with rate of 80/min, normal axis with normal PR, and QT intervals with normal QRS.

STT changes were present in anterior chest leads from V1-V4 in form of ST segment depression and T wave inversions, no ST elevations seen in any leads.

FINAL DIAGNOSIS

UNSTABLE ANGINA

TREATMENT

Emergency management was done with

S/L angisid 0.5 mg stat

Asprin 300 mg stat

Clopidogrel 300 mg stat

Morphine 3mg stat

Metoprolol 25 mg stat

Infusion of isoket @ 10 u drops/min

Clexane 80 mg S/C Stat

Chest pain improved with medication and

ECG also showed improvement

TIMI RISK SCORE

CORONARY ANGIOGRAM

• Patient was offered coronary angiogram as it was Class I A indication according to AHA guidelines

• Recommendations for Coronary Angiography in Unstable Coronary Syndromes

Class I

High- or intermediate-risk unstable angina that stabilizes after initial treatment. (Level of Evidence: A)

REVISED TIMI RISK SCORE

DECISION

Patient was advised PTCA for his disease and for the complete decision we will have

to review the type of lesion we r facing

How to define a bifurcation lesion ?

• “A coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch"

• A significant SB is a branch that you don't want to loose in the global context of a particular patient

Difficulties of Bifurcation PCI

• Risk of peri-procedural complications• Relatively high re-stenosis• Not all lesions are the same :

- Size of vessels (Meaningful SB size ≥2.25mm)

- Variable plaque distribution - Extent of SB disease - Variable angulations

• Higher risk of stent thrombosis• PCI techniques are mainly based on

personal experiences from skilled operators

Factors to be considered for PCI strategy

• Anatomical factors– LMCA bifurcation– Location of plaque (Anatomical classification)– Plaque or carina shift– Angle between SB and MB– Dynamic change in bifurcation anatomy

• Modalities for objective anatomical evaluation– QCA, IVUS, FFR

• Selection of devices and strategies– DES vs. BMS– Single vs. Double stent techniques– Kissing balloon or not– Dedicated bifurcation stents

Classification ofBifurcation Lesions

• Plaque Location• Plaque Extent• Angle

Classifications of bifurcation lesions

Medina Classification

Limitations ofthe Medina classification

• Does not take into account1. Length of disease in the ostium of

the SB

2. Length of the LMCA before the bifurcation

3. Trifurcation

4. Vessel angulation

• The LMCA differs from many other bifurcation lesions due to the importance of the SB (LCx)

Plaque Burden at the SB Ostium

Trifurcation

Angulation

Fractal geometry and QCA

How to name a bifurcation lesion

Medina Classification

SIDE BRANCH LOSS

Simple

Stents and Dedicated Delivery Systems

Drug-eluting Stents in Bifurcation Lesions – Safety Data

The Technique Matters more than the Number of Stent ?

CONCLUSION

In cases where there is no lesion in the side branch or a purely ostial lesion, stenting the main branch with a jailed wire in the side branch followed by provisional T-Stenting of the side branch after guide wire exchange appears to be the most rational and successful strategy, provided that final kissing-balloon inflations are systematically performed.

KEEP YOUR GOAL IN SIGHT

WORK HARD

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THANK YOU !!!