1. Lesson 4 What is the treatment for Coronary Artery Disease?

2. Initial Interventions for MI
EKG upon arrival to ER
MONA- Morphine, oxygen, Nitroglycerin, Aspirin.
Beta Blocker- Lopressor or Atenolol.
Anti-arrhythmic if needed. Examples Lidocaine, Amiodarone
Anticoagulation therapy. Example Heparin infusion.
Thrombolytic Therapy- Examples Streptokinase, tPA,TNKase. Used to dissolve clots.
The goal is reperfusion to prevent necrosis (deadening) of the heart tissue.

3. Percutaneous Coronary Revascularization (PCR)
PCR is the process of restoring blood flow to the heart.
The process is completed by bypassing the blockage or blockages in the coronary arteries.
The procedure is performed though the skin using a small flexible catheter threaded through a blood vessel.

4. PCR continued
Several types of procedures can be performed to restore blood flow. For example
Atherectomy- A drill is used to shave plaque.
Laser Ablation- Fiberoptic probe used with laser to burn plaque away.
Coronary Artery Balloon Angioplasty- A catheter with a tiny balloon is carefully guided through the coronary artery to the blockage, then inflated to widen the opening and increase blood flow to the heart. A stent is often placed during the procedure to keep the artery open after the balloon is deflated and removed.
Coronary Artery Stenting – A stainless steel stent is placed in the narrowing of the artery to push against the artery wall to help the artery to remain open.

5. Complications During the Procedure
Dissection of the artery
Perforation of the artery
Abrupt closure of the artery
Vasospasms
Myocardial Infarction
Cardiac Arrest

6. Complications Post Procedure
Bleeding
Weakened or lost pulses distal to the sheath insertion site.
Retroperitoneal bleeding
Pseudoaneurysm and arteriovenious fistula .

7. Coronary Artery Bypass (CABG)
CABG is performed on those patients with significant coronary artery blockage or blockages.
The purpose of the procedure is to bypass (go around) arteries that have become blocked and create a new route for blood to flow to the heart muscle.

8. CABG
A CABG is performed by making an incision in the middle of the chest referred to as a sternal incision.
Cardiopulmonary bypass must be established. Tubes are placed in the right atrium to redirect venous blood out of the body for passage through a membrane oxygenator in the heart lung machine.
Then the oxygenated blood is returned to the body.
The main aorta is clamped off during the CABG surgery to maintain a bloodless field and to allow bypasses to be connected to the aorta.
The greater saphenous vein and internal mammary artery are the commonly used vein/artery for bypassing grafting.

9. CABG continued
The graphed vessels must then be sewn to coronary arteries below the blockage.
Next the other end of the vessel is sewn to the aorta.
Complications include heart attack, bleeding complications, chest infection, respiratory complications, stroke, and cardiac tamponade.

10. Comparing PCR to CABG
According to the article Propensity Analysis of Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease and High-Risk Features; Effective comparison of CABG and PCI in RCTs and registries is affected by patient and procedure selection bias, the duration of follow-up, and the type of events studied.50 Thus, analysis at an interval of 5 years favors, to a certain extent, CABG patients because it precedes the development of severe graft disease while capturing most events in the PCI cohort. Despite these limitations, we conclude that at a large tertiary institution with particularly low surgical mortality, patients with multivessel CAD and many high-risk features appear to have a better 5-year survival when treated with CABG than with PCI. Further research is needed to determine whether drug-eluting stents and improved medical management will close the mortality gap in these patients.

11. Comparison Continued.
In the Journal of the American College of Cardiology this article Comparison of Coronary Artery Bypass Surgery With Percutaneous Coronary Intervention With Drug-Eluting Stents for Unprotected Left Main Coronary Artery Disease presented information that supported the outcome PCI.
In the study Fifty patients underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES), and 123 patients underwent coronary artery bypass graft (CABG) surgery for unprotected left main coronary artery (ULMCA) disease at our institution. The estimated major adverse cardiac and cerebrovascular event-free survival at six months and one year were 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20); PCI with DES for ULMCA disease appears to be safe and is not associated with an increase in short- and intermediate-term complication rates compared with CABG.