1. Coronary Artery Disease: Diagnosis and Treatment
Northwestern Memorial Hospital Healthy Transitions Fall Program October 7, 2013
Coronary Artery Disease: Diagnosis and Treatment
Mark J. Ricciardi, MD
Director, Interventional Cardiology and Cardiac Catheterization
Northwestern Bluhm Cardiovascular Institute

2. Outline Coronary artery disease (CAD) basics Diagnosis of CAD
Cardiac Catheterization / Coronary Angiography
Treatment of CAD
Coronary Angioplasty / Stent
Past, present, future

3. Coronary Disease Atherosclerosis ‘Arteriosclerosis’
Fatty buildup in lining of artery wall
Plaque
Impinges on flow
Reduces amount of blood and oxygen delivered to the heart muscle

4. Cholesterol deposition

5. Early CAD

6. Vulnerable Plaque
Plaque Rupture

7. Coronary Thrombosis “Heart Attack”

8. CAD the goal… is prevention Primary prevention
Prevent early / sub-clinical stages
Heart healthy lifestyle
Starting in childhood
Medications
Targeted at high risk groups

9. Diagnosis of CAD
History
Symptoms
Angina

10. Diagnosis of CAD History Non-invasive imaging Symptoms Angina
Stress testing
provocation
CT angiogram
good, not great

11. Diagnosis of CAD Invasive imaging History Non-invasive imaging
Symptoms
Angina
Non-invasive imaging
Stress testing
CT angiogram
Invasive imaging
Left heart catheterization / coronary angiography … the gold standard for Dx

12. Coronary Angiography Purposes
Define coronary anatomy, and presence, absence, degree obstruction
Most commonly used to:
determine extent of CAD
assess feasibility and appropriateness of mechanical revascularization

13. Catheterization

14. Catheterization

15. Coronary Angiography

16. Coronary Angiography

17. Arterial access Femoral artery
Most common access site
since 1980s
Easy and reliable
Often requires minutes of pressure to prevent bleeding - followed by bed-rest
1% risk significant bleeding
There are new strategies that hasten recovery time
Bleeding still an issue

18. Arterial access Radial artery
Lower risk of significant bleeding
No bed rest required

19. Arterial access Radial artery

20. Arterial access Radial artery
“Down side” -the learning curve

21. CAD Treatment

22. CAD Treatment The past…

23. CAD Treatment Secondary prevention Lifestyle modification
Diet, exercise, tobacco cessation
Rx underlying risk factors
Aspirin and ‘statin’ medications
Anti-anginal medications
Beta blockers

24. Coronary Bypass

25. Coronary Angioplasty

26. Coronary Angioplasty

27. Coronary Stenting

28. Coronary Stenting

29. Drug Stents

30. Northwestern Memorial Hospital Cardiac Catheterization Center
Chicagoland’s First:
Coronary Stent (1990s)
Drug eluting stent (early 2000s)

31. Northwestern Memorial Hospital Cardiac Catheterization Center
Chicagoland’s First:
Coronary Stent (1990s)
Drug eluting stent (early 2000s)
Bio-absorbable stent (2013)

32. Next Generation Stents
Bioabsorbable / dissolving stents
In clinical trials at Northwestern

33. Conclusions CAD Symptomatic CAD CAD Treatment
Sub-clinical plaque formation
Symptomatic CAD
Angina, heart attack
Non-invasive and invasive testing
CAD Treatment
Behavioral, pharmacologic, mechanical
NW big part of the past, present and future of CAD Rx

34. Questions?

36. Judkins Technique JL and JR catheters Melvin Judkins
Radiology associate of Charles Dotter at University of Oregon, had studied coronary angiography with Dr. Mason Sones. Went on to create own system of diagnostic imaging, introducing a series of specialized catheters and perfecting transfemoral approach (introducing the catheter via a groin puncture rather than the more complex procedure used by Sones of introducing the catheter via surgical opening of the brachial artery in the arm). 
Ptca.org

37. Cineangiography Angiographic views

38. Femoral Artery Hemostasis Perclose Suture-Mediated Closure System (Abbott Vascular)
Non-braided polyester suture
Automated knot tying
Closure of 5-8Fr. access sites
‘pre-closure’

39. Transradial Angiography / Intervention Anatomy
No associated major nerve
Median N in carpal tunnel
Ulnar N runs with UA
Dual arterial supply to hand
RA and UA join in 2 arches
Superficial and deep palmar arches
#1 you can get to the heart from here. #2 dual supply to hand

40. Radial Artery Compression Devices

42. The most important bleeding avoidance strategy?
Femoral
Radial