Angioplasty

6,609 views

Published on

Published in: Health & Medicine
0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
6,609
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
295
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

Angioplasty

  1. 1. Heart of the Matter 23 rd November 2010 Steve Leslie Interventional Cardiologist Highland What, Why and Where? Coronary Angioplasty in NHS Highland
  2. 2. Burden of coronary disease Eur Heart J 2008 29:1316-1326 Coronary Heart Disease Statistics (2003)
  3. 3. What, Why and Where? <ul><li>What is coronary angioplasty? </li></ul><ul><li>Why do we do it (which patients)? </li></ul><ul><li>Where should it be done? </li></ul>
  4. 4. Definitions <ul><li>Angiography = pictures of blood vessels </li></ul><ul><li>Angioplasty = changing shape of blood vessel </li></ul><ul><li>PCI = Percutaneous Coronary Intervention </li></ul><ul><li>PPCI = Primary PCI = PCI during acute infarction </li></ul><ul><li>Rescue PCI = PCI if lysis failed </li></ul>
  5. 5. Questions (blue = yes) <ul><li>Primary PCI saves lives </li></ul><ul><li>PCI in stable angina saves lives </li></ul><ul><li>PCI can be done as a day case </li></ul><ul><li>PCI is cheaper than CABG </li></ul><ul><li>After PCI, patients should not drive for 1 week </li></ul><ul><li>After PCI, patients should not work for 1 month </li></ul>
  6. 6. Human angioplasty <ul><li>1974 — Andreas Gruentzig performs first peripheral human balloon angioplasty </li></ul><ul><li>1976 — Gruentzig presents results of animal studies of coronary angioplasty at AHA meeting </li></ul>
  7. 7. Coronary angioplasty <ul><li>1977 — First human coronary balloon angioplasty performed intraoperatively </li></ul><ul><li>1977 — Andreas Gruentzig performs first cath lab PCI on awake patient in Zurich; starting with this case, all PCI data is entered into a registry </li></ul>
  8. 8. Standard PCI kit Guiding catheters Guidewires Angioplasty balloon Deployed stent
  9. 9. New developments
  10. 10. Evolution of Angioplasty High success Low morbidity Dr. Don Baim, FDA Panel Meeting December 2006 0 10 20 30 40 POBA early POBA late Stent early Stent late DES Event Rate % 1977 1985 1997 1994 2003-present Failure Em CABG Restenosis Stent thrombosis VLST Innovations over time
  11. 11. What does the patient experience? <ul><li>FEAR! </li></ul>
  12. 12. Cardiac Catheterisation Laboratory (the ‘cath lab’)
  13. 13. Cath Lab Team <ul><li>CCU / ward staff / ITU </li></ul><ul><li>Cardiology medical staff </li></ul>
  14. 14. Coronary angioplasty
  15. 15. Post procedure care <ul><li>Puncture site </li></ul><ul><li>Day case ~50% </li></ul><ul><li>No driving for 1 week </li></ul><ul><li>Encourage early back to work </li></ul><ul><li>No change to tablets (except clopidogrel) </li></ul><ul><li>~3 month review </li></ul>
  16. 16. Risk of Stent thrombosis
  17. 17. Why do we do it (which patients)? <ul><li>Myocardial Infarction </li></ul><ul><ul><li>NSTEMI ~600/pa </li></ul></ul><ul><ul><li>STEMI ~100/pa </li></ul></ul><ul><li>Chronic Stable Angina </li></ul><ul><ul><li>??% of 10,000 </li></ul></ul><ul><li>Asymptomatic Ischaemia </li></ul>
  18. 18. Fox et al . Lancet 2002; 360 :743-751 Non STEMI (n~600)
  19. 19. TIMI Risk Score <ul><li>Age ≥ 65 years </li></ul><ul><li>≥ 3 Risk factors for coronary artery disease </li></ul><ul><li>Significant coronary stenosis </li></ul><ul><li>ST Segment deviation </li></ul><ul><li>Severe anginal symptoms (≥2 anginal events in last 24 hours) </li></ul><ul><li>Prior aspirin use (within last 7 days) </li></ul><ul><li>Elevated serum cardiac markers </li></ul>Antman et al . JAMA 2000; 284 :835-842
  20. 20. <ul><li>MEN </li></ul><ul><li>≥ 65 YEARS </li></ul><ul><li>CHRONIC ANGINA </li></ul><ul><li>NON-SMOKERS </li></ul><ul><li>CHEST PAIN at REST </li></ul><ul><li>(TROPONIN +VE) </li></ul><ul><li>ST DEPRESSION </li></ul>FRISC II et al . Lancet 1999; 354 :708-715 FRISC II
  21. 21. Why do we do it (which patients)? <ul><li>Myocardial Infarction </li></ul><ul><ul><li>NSTEMI ~600/pa </li></ul></ul><ul><ul><li>STEMI ~100/pa </li></ul></ul><ul><li>Chronic Stable Angina </li></ul><ul><ul><li>??% of 10,000 </li></ul></ul><ul><li>Asymptomatic Ischaemia </li></ul>
  22. 22. STEMI (n~100) <ul><li>Thrombolysed STEMI (3-24hrs) </li></ul><ul><li>Rescue PCI (immediate) </li></ul><ul><li>Primary PCI (immediate) </li></ul>
  23. 23. Primary PCI 33 38% 3% 5% 8% Long term mortality (6-18months) 33 36% 3% 5% 8% Short term mortality (4-6weeks) PCI Thrombolysis NNT Relative RR Absolute RR Event Rate Clinical indices Advantages of primary percutaneous coronary intervention over thrombolysis. 81 When this cannot be achieved within 90 minutes of diagnosis patients should receive immediate thrombolytic therapy D Patients with an ST elevation acute coronary syndrome should be treated immediately with PPCI A Those presenting < 6hours who fail to reperfuse should be considered for rescue PCI B
  24. 24. Heart Attack Centres population 340,000 Elderly migrant population Holiday influx
  25. 25. Drive times
  26. 26. What are the PPCI issues at Raigmore? <ul><li>4 cardiologists </li></ul><ul><li>(2 interventional cardiologists) </li></ul><ul><li>Small patient volume </li></ul><ul><li>Dispersed population </li></ul>
  27. 27. Answers <ul><li>Primary PCI saves lives </li></ul><ul><li>PCI in stable angina does not saves lives </li></ul><ul><li>PCI can be done as a day case </li></ul><ul><li>PCI is not cheaper than CABG </li></ul><ul><li>After PCI, patients should not drive for 1 week </li></ul><ul><li>After PCI, patients should return to work soon </li></ul>
  28. 28. Future <ul><li>Public Health </li></ul><ul><li>Rationing </li></ul><ul><li>Risk stratification </li></ul><ul><li>Other imaging </li></ul>
  29. 29. Not just about plumbing!
  30. 30. Thank you

×