Coronary Artery Disease: Coronary Artery Disease: Diagnosis and TreatmentDiagnosis and Treatment

Mark J. Ricciardi, MDMark J. Ricciardi, MDDirector, Interventional Cardiology and Cardiac Director, Interventional Cardiology and Cardiac CatheterizationCatheterizationNorthwestern Bluhm Cardiovascular InstituteNorthwestern Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

Healthy Transitions Fall ProgramOctober 7, 2013

OutlineOutline

Coronary artery disease (CAD) basicsCoronary artery disease (CAD) basics Diagnosis of CADDiagnosis of CAD

– Cardiac Catheterization / Coronary Cardiac Catheterization / Coronary AngiographyAngiography

Treatment of CADTreatment of CAD– Coronary Angioplasty / StentCoronary Angioplasty / Stent– Past, present, futurePast, present, future

Coronary DiseaseCoronary Disease

AtherosclerosisAtherosclerosis– ‘‘Arteriosclerosis’Arteriosclerosis’– Fatty buildup in lining of artery wallFatty buildup in lining of artery wall

Plaque Plaque

– Impinges on flow Impinges on flow Reduces amount of blood and oxygen Reduces amount of blood and oxygen

delivered to the heart muscledelivered to the heart muscle

Cholesterol depositionCholesterol deposition

Early CADEarly CAD

Vulnerable Plaque

Plaque Rupture

Coronary ThrombosisCoronary Thrombosis“Heart Attack”“Heart Attack”

CADCADthe goal…the goal…

is preventionis prevention– Primary preventionPrimary prevention

Prevent early / sub-clinical stagesPrevent early / sub-clinical stages Heart healthy lifestyleHeart healthy lifestyle

– Starting in childhoodStarting in childhood MedicationsMedications

– Targeted at high risk groupsTargeted at high risk groups

Diagnosis of CADDiagnosis of CAD

History History – SymptomsSymptoms– AnginaAngina

Diagnosis of CADDiagnosis of CAD

History History – SymptomsSymptoms– AnginaAngina

Non-invasive imagingNon-invasive imaging– Stress testingStress testing

provocationprovocation

– CT angiogramCT angiogram good, not greatgood, not great

Diagnosis of CADDiagnosis of CAD

History History – SymptomsSymptoms– AnginaAngina

Non-invasive imagingNon-invasive imaging– Stress testingStress testing– CT angiogramCT angiogram

Invasive imagingInvasive imaging– Left heart catheterization / coronary Left heart catheterization / coronary

angiography … the gold standard for Dxangiography … the gold standard for Dx

Coronary AngiographyCoronary AngiographyPurposesPurposes

Define coronary anatomy, and Define coronary anatomy, and presence, absence, degree presence, absence, degree obstructionobstruction

Most commonlyMost commonly used to: used to: – determine extent of CAD determine extent of CAD – assess feasibility and appropriateness of assess feasibility and appropriateness of

mechanical revascularizationmechanical revascularization

CatheterizationCatheterization

CatheterizationCatheterization

Coronary AngiographyCoronary Angiography

Coronary AngiographyCoronary Angiography

Arterial access Arterial access Femoral arteryFemoral artery

Most common access siteMost common access site– since 1980ssince 1980s

Easy and reliableEasy and reliable

Often requires 20-30 Often requires 20-30 minutes of pressure to minutes of pressure to prevent bleeding - followed prevent bleeding - followed by bed-restby bed-rest

1% risk significant bleeding1% risk significant bleeding There are new strategies There are new strategies

that hasten recovery timethat hasten recovery time– Bleeding still an issueBleeding still an issue

Arterial access Arterial access Radial arteryRadial artery

Lower risk of Lower risk of significant bleedingsignificant bleeding

No bed rest requiredNo bed rest required

Arterial access Arterial access Radial arteryRadial artery

““Down side” Down side”

-the learning -the learning curvecurve

Arterial access Arterial access Radial arteryRadial artery

CAD TreatmentCAD Treatment

CAD TreatmentCAD TreatmentThe past…The past…

CAD TreatmentCAD Treatment

Secondary preventionSecondary prevention– Lifestyle modificationLifestyle modification

Diet, exercise, tobacco cessationDiet, exercise, tobacco cessation Rx underlying risk factorsRx underlying risk factors

– Aspirin and ‘statin’ medicationsAspirin and ‘statin’ medications– Anti-anginal medicationsAnti-anginal medications

Beta blockersBeta blockers

Coronary BypassCoronary Bypass

Coronary AngioplastyCoronary Angioplasty

Coronary AngioplastyCoronary Angioplasty

Coronary StentingCoronary Stenting

Coronary StentingCoronary Stenting

Drug StentsDrug Stents

Northwestern Memorial Hospital Northwestern Memorial Hospital

Cardiac Catheterization CenterCardiac Catheterization Center

Chicagoland’s First:Chicagoland’s First:– Coronary Stent (1990s)Coronary Stent (1990s)– Drug eluting stent (early 2000s)Drug eluting stent (early 2000s)

Northwestern Memorial Hospital Northwestern Memorial Hospital

Cardiac Catheterization CenterCardiac Catheterization Center

Chicagoland’s First:Chicagoland’s First:– Coronary Stent (1990s)Coronary Stent (1990s)– Drug eluting stent (early 2000s)Drug eluting stent (early 2000s)– Bio-absorbable stent (2013)Bio-absorbable stent (2013)

Next Generation StentsNext Generation Stents

Bioabsorbable / Bioabsorbable / dissolving stentsdissolving stents

In clinical trials at In clinical trials at NorthwesternNorthwestern

ConclusionsConclusions

CADCAD– Sub-clinical plaque formationSub-clinical plaque formation

Symptomatic CADSymptomatic CAD– Angina, heart attackAngina, heart attack– Non-invasive and invasive testingNon-invasive and invasive testing

CAD TreatmentCAD Treatment– Behavioral, pharmacologic, mechanicalBehavioral, pharmacologic, mechanical– NW big part of the past, present and NW big part of the past, present and

future of CAD Rxfuture of CAD Rx

Questions?Questions?

http://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=angiog

http://www.scai.org/PatientEducation/default.aspx

Judkins TechniqueJudkins Technique

JL and JR cathetersJL and JR catheters Melvin JudkinsMelvin Judkins

CineangiographyCineangiographyAngiographic viewsAngiographic views

Femoral Artery Hemostasis Femoral Artery Hemostasis Perclose Suture-Mediated Closure System Perclose Suture-Mediated Closure System (Abbott Vascular)(Abbott Vascular)

Non-braided polyester Non-braided polyester suturesuture

Automated knot tyingAutomated knot tying Closure of 5-8Fr. access Closure of 5-8Fr. access

sites sites

‘‘pre-closure’pre-closure’

Transradial Angiography / Transradial Angiography / InterventionInterventionAnatomyAnatomy

No associated major nerveNo associated major nerve Median N in carpal tunnelMedian N in carpal tunnel Ulnar N runs with UAUlnar N runs with UA

Dual arterial supply to handDual arterial supply to hand RA and UA join in 2 arches RA and UA join in 2 arches Superficial and deep palmar archesSuperficial and deep palmar arches

Radial Artery Compression Radial Artery Compression DevicesDevices

The most important The most important bleeding avoidance bleeding avoidance strategy?strategy?

FemoralFemoral RadialRadial