Coronary Arteries


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Introduction to coronary arteries, tests, and treatments, with brief look at peripheral arterial disease.

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  • As you may know, the aortic valve has three cusps, two of which are coronary cusps, with the third being a non-coronary cusp (not a very inventive name).
  • Those in the cath lab know this from ACC database…
  • The one that seems most common is the first example…
  • Anomalous origin from PA is a congenital defect that can have a mortality rate of 90% in the first year of life, due to MI or MR leading to CHF- prognosis improves with early detection by echo and improved surgical techniques…(
  • Knowledge of myocardial blood supply comes in handy when interpreting an ECG…
  • Especially in an acute MI situation, knowing which artery is having the infarct can give you an idea of the amount of heart muscle involved, which can be a large factor in the patient’s prognosis…
  • An IABP inflates during diastole, which will push more blood down the coronaries when the LV has been damaged…
  • We use NTG intracoronary to get a truer size of the vessel, and also to relieve any spasm that may be present..Injecting IIbIIIa inhibitors can be especially helpful with acute MI, when there is visible clot present in the vessel…not FDA approved.
  • How do we find as many of these people as possible before the MI happens?
  • So, what are the options for a patient with significant CAD?
  • MasonSones, Cleveland Clinic, catheter for Ao root shot went into RCA by accident- he saw, but before he could reposition, the contrast was injected- pt had to cough themselves out of aystole…
  • Coronary Arteries

    1. 1. Coronary Arteries<br />The Basics and Beyond<br />
    2. 2. Function of coronary arteries: delivery of oxygenated blood to the heart muscle (myocardium)<br />The VERY Basics<br /><br />
    3. 3. Left coronary artery: arises from the left coronary sinus/cusp of the Aortic valve<br />Left main artery branches into:<br />LAD- Left Anterior Descending <br />CX- Circumflex<br />Right coronary artery: arises from the right coronary sinus/cusp of the Aortic valve<br />Main Branches<br />
    4. 4. Coronary arteries lie on top of the myocardium (epicardial) and follow the Atrioventricular (AV) groove and the Interventricular (IV) groove<br />CX courses along AV groove<br />LAD and distal RCA follow IV groove<br />Basics, cont<br />
    5. 5.<br />
    6. 6. LAD: diagonals and septals<br />CX: obtuse marginals, occasionally Posterior descending artery (PDA)<br />RCA: acute marginals, Posterior lateral artery (PLA), and PDA<br />Ramusintermedius: arises between LAD and CX in 5%-10% of population<br />Major Branches<br />
    7. 7. A person can be “right dominant”, “left dominant”, or “co-dominant”.<br />This depends on which artery (or arteries) give rise to the PDA and PLA, which run along the posterior side of the heart.<br />Coronary Dominance<br />
    8. 8. Right Dominant<br />The PDA branch arises from the RCA (60%-70% of population)<br />
    9. 9. Left Dominant<br />The PDA arises from the LCA (10%-15% of population)<br />
    10. 10. RCA gives rise to the PDA and then ends, while the CX supplies the PLA branches<br />CX may also supply a left PDA that runs parallel to the right PDA<br />Co-Dominant<br />
    11. 11. As with all structures in the human body, WEIRD stuff can happen! A few examples:<br />CX originates with RCA from right sinus<br />LM from right sinus<br />RCA from left sinus<br />Separate originations (ostia) for all three<br />All three arteries from one ostia<br />Variations and Anomalies<br />
    12. 12. Coronary aneurysms<br />Fistulas- abnormal communication with venous system<br />Anomalous origin of LCA from Pulmonary Artery (defect that can have a mortality rate of 90% in first year of life, due to MI or MR leading to CHF)<br />Anomalies<br />
    13. 13. Adventitia- outermost, connective tissue covering the vessel<br />Media- smooth muscle cells<br />Spasm- contraction of cells causing disturbance of blood flow (caused by numerous factors: caffeine or stimulant induced, catheter induced)<br />Intima- innermost, single layer of cells<br />Anatomy of an Artery<br />
    14. 14.<br />
    15. 15.
    16. 16. LAD supplies: most of septum, anterior/lateral/apical LV, anterolateral pap muscle<br />CX supplies: LA, posterior/lateral LV, anterolateral pap muscle, SA node (45%), AV node (10%), septum, His bundle, posterior pap muscle, inferoposterior LV<br />RCA supplies: SA node (55%), RA, AV node (90%), septum, His bundle, posterior pap muscle, inferoposterior LV<br />Myocardial Blood Supply<br />
    17. 17. Myocardial Blood Supply<br /><br />
    18. 18. Coronary Arteries perfuse in diastole (this is part of the theory behind the IABP)<br />Coronary sinus collects used blood from the mycardium to send to lungs for re-oxygenation<br />Coronary bridging = compression of a coronary artery by the myocardium during systole<br />Usually benign, but can occasionally result in MI or even death (most common with LAD)<br />Hemodynamics<br />
    19. 19. Several medications are injected to elicit vasodilation in the arteries during catheterization, such as diltiazem, verapamil, adenosine, nitroglycerine, and nipride<br />IIbIIIa Inhibitors (abciximab, eptifibitide) are also directly injected in coronary arteries with apparent thrombus<br />Pharmacology<br />
    20. 20. CAD and Atherosclerosis: What does this mean, exactly?<br />Build-up of fatty substances, cholesterol, cellular waste products, and calcium within the intima of an artery<br />With or without symptoms<br />Coronary Artery Disease<br />
    21. 21. Pathophysiology of CAD<br />
    22. 22. Rupture of fibrous cap<br />Platelets rush in to fix the vessel<br />Clot forms<br />Blood flow obstructed<br />Damage/death of myocardium<br />Pathophysiology of Acute MI<br />
    23. 23. Many tests and screening tools are available to help detect CAD<br />Can be invasive or non-invasive<br />Can be performed in MD’s office or hospital, depending on type of test<br />Diagnostic Testing Methods<br />
    24. 24. Treadmill- assesses coronary blood flow by ECG, blood pressure, and signs/symptoms during exercise<br />Stress Tests<br />
    25. 25.
    26. 26. Stress Echocardiogram-compares LV wall motion at rest and under stress<br />Used for low-moderate risk patients and younger patients where there may be structural/valvular/congenital causes of symptoms<br />Stress Tests<br /><br />
    27. 27. Perfusion scan- compares blood flow at rest and under stress by imaging the myocardium after a radioactive tracer is injected<br />Stress Tests<br /><br />
    28. 28. Echocardiogram- assesses structural, valvular, and congenital causes of heart disease<br />Diagnostic Testing<br /><br />
    29. 29. Cardiac MRI- useful for diagnosis of structural disease (cardiomyopathy, masses) with or without contrast<br />Gold standard for congenital heart disease<br />Diagnostic Testing<br />
    30. 30. Cardiac Computed Tomography(CT)- evaluates coronary arteries as well as LV function, anatomy, and calcification (calcium score)<br />Diagnostic Testing<br /><br />
    31. 31. Cardiac CT Images<br /><br /><br />
    32. 32. Coronary Angiography- used for positive and indeterminate stress tests, assessment of bypass grafts<br />Also for patients with known history of CAD<br />Gold standard for coronary evaluation<br />Diagnostic Testing<br /><br />
    33. 33. IVUS- small ultrasound catheter is inserted in the coronary artery to image the vessel and assess plaque<br />Can differentiate between fibrous and calcified plaque<br />Virtual histology<br />Diagnostic TestingIntravascular Ultrasound<br /><br />
    34. 34. Technically: the ratio of blood flow in a stenotic artery to normal flow<br />Essentially: a stress test on a specific artery<br />Flow is measured by a special guidewire, using flow measurements beyond the lesion and comparing them with flow before the lesion<br />IV infusion of Adenosine is used to increase HR <br />Ratio is calculated from a 2-3 minute period<br />Normal value = 1.0<br />Abnormal value = <0.75<br />Diagnostic TestingFractional Flow Reserve (FFR)<br />
    35. 35. Treatment of CAD<br />Medical treatment- managing the patient’s medications to help alleviate symptoms<br />Percutaneous Coronary Intervention (PCI)- used in various situations, from single lesions to complex, high-risk multi vessel disease<br />
    36. 36.<br />
    37. 37. Treatment of CAD<br />Coronary Artery Bypass Grafting- most often used for severe multi vessel disease and diabetic patients<br /><br />
    38. 38. We’ve come a long way from the first accidental coronary angiogram in 1958…<br />Diagnosis and treatments continue to evolve<br />Coronary Arteries Summary<br />
    39. 39. Peripheral Arterial Disease (PAD)<br />Same arterial anatomy and disease process, but most patients (with exception of CVA) tend to wait much longer to seek treatment<br />May mimic arthritis, neuropathy<br />Symptoms attributed to “old age”<br />What about Peripheral Vascular Disease?<br />
    40. 40. Claudication- leg pain with walking that resolves at rest<br />Decreased temperature of extremity<br />Non-healing wounds<br />Symptoms of LE PAD<br />
    41. 41. Sudden numbness or weakness, especially on one side<br />Sudden confusion, trouble speaking<br />Sudden trouble seeingin one or both eyes<br />Sudden dizziness, loss of balance and coordination<br />Sudden severe headache<br />Symptoms of CVA<br />
    42. 42. Ultrasound/Doppler studies<br />MRI/MRA<br />CT/CTA<br />Angiography<br />Diagnostic Testing for PAD<br />
    43. 43. Medications<br />PercutaneousTransluminal Angioplasty (PTA) with or without stent placement<br />Atherectomy<br />Bypass surgery<br />Treatment of PAD<br />
    44. 44. Interventions done for high-risk, asymptomatic or symptomatic patients (depends on clinical study enrollment)<br />All patients must be enrolled in a research study to receive a stent<br />Typical criteria: asymptomatic with >80% stenosis by ultrasound, or symptomatic with >50% stenosis and at least one high-risk factor, such as age>80 years, CHF, severe COPD, previous CEA with restenosis, previous radiation therapy or neck surgery, lesion location<br />Carotids<br />
    45. 45. Cleveland Clinic Heart and Vascular Institute<br />
    46. 46. Code Stroke<br />An Interdisciplinary effort to get treatment started for stroke victims ASAP<br />Emcompasses: ED assessment, activation of Code Stroke protocol, Neurology consults, CT scans, Interventional Cardiology consults, thrombolytic treatment if indicated, invasive intervention if indicated<br />
    47. 47. Renals<br />Interventions performed for poorly controlled hypertension or poor renal function<br /><br />
    48. 48. Interventions performed for claudication, critical limb ischemia (non healing wounds), and limb salvage<br />Lower Extremity<br />
    49. 49.<br />
    50. 50. PAD<br />Basically, if we can get a catheter to an artery, we can take a picture and potentially intervene!<br />Mesenterics<br />Subclavians<br />ETC…<br />
    51. 51. Fast growing segment of cardiac cath lab procedures<br />Percutaneous treatments are constantly being developed<br />PAD Summary<br />
    52. 52.<br /><br />NEJM, Vol. 360 No.3<br /><br />Encyclopedia Brittanica<br /><br /><br /><br /><br />Nature Publishing Group<br /><br />Sources<br />
    53. 53.<br /><br /><br /><br /><br /><br />Cleveland Clinic Heart and Vascular Institute<br /><br /><br /><br /><br />Sources<br />