1. Unstable angina and arterial hypertension Leszek Kinasz, MD American Heart of Poland Ustron, Poland

2. Clinical data Female, 59 years old Female, 59 years old Unstable angina (CCS class 4) Unstable angina (CCS class 4) Hypertension since 1999, currently required 4 drugs (ACEI, beta-blocker, duretic, calcium channel blocker) Hypertension since 1999, currently required 4 drugs (ACEI, beta-blocker, duretic, calcium channel blocker) Hypercholesterolaemia Hypercholesterolaemia History of pulmonary oedema History of pulmonary oedema BMI 35 BMI 35

3. Clinical data RR 220/120 RR 220/120 HR 64/min HR 64/min Pulmonary congestion Pulmonary congestion EKG: ST depression and negative T wave in inferior and lateral leads EKG: ST depression and negative T wave in inferior and lateral leads UKG: LVEF 55%, hypokinesia of inferior segments, MVI(+) UKG: LVEF 55%, hypokinesia of inferior segments, MVI(+) Lab tests: CPK, CPK-MB, Troponin I - normal, Creatinine 1.4 mg% Lab tests: CPK, CPK-MB, Troponin I - normal, Creatinine 1.4 mg%

4. Coronary angiography (CAG) RCA LAO60: 99% lesion in distal segment type B2 LCA RAO30, Caud 15 Normal epicardial segments

5. PCI: 7F JR guiding cath, 0,014” BMW wire, RCA LAO60: predilatation and stent positioning (BX Velocity 3.0x18 mm) After stenting: max. pressure 18atm

6. After PCI: Persisted chest pain and ST/T changes on the EKG monitor Persisted chest pain and ST/T changes on the EKG monitor RR 200/120 -a rigorous treatment of hypertension (NTG i.v. and i.a., Furosemid i.v., nifedipine s.l.) without effect on angina RR 200/120 -a rigorous treatment of hypertension (NTG i.v. and i.a., Furosemid i.v., nifedipine s.l.) without effect on angina

7. What is a cause of the chest pain? Occlusion of a small AM branch? Occlusion of a small AM branch? AM

8. Hypertension? If so, what should be done next? 1. More intensive pharmacological treatment 2. Further diagnosis of hypertension Hypertension? If so, what should be done next? 1. More intensive pharmacological treatment 2. Further diagnosis of hypertension What is a cause of the chest pain?

9. Renal angiography Right renal artery Left renal artery Angio performed in AP view, with Right Judkins catheter used previously for PCI

10. Renal stenting as a one-stage procedure with PCI: Renal stenting: Guiding catheter: 7F, Judkins Right Wire: 0,014” BMW Stent: Corinthian 6.0mm, 14 atm, Left renal artery after stenting

11. Diagnostic cath, PCI and Renal Stenting as one-stage procedure: Coronary diagnostic catheters:2 Coronary diagnostic catheters:2 No of wires: 1 No of wires: 1 No of guiding catheters:1 No of guiding catheters:1 No of balloon catheters:1 No of balloon catheters:1 No of stents:2 No of stents:2 Contrast: Ultravist 190 ml Contrast: Ultravist 190 ml X-Ray exposition10.5 min. X-Ray exposition10.5 min.

12. After the procedure No chest pain No chest pain Arterial pressure: 150/90 Arterial pressure: 150/90 Resolution of ST/T changes in serial ECG Resolution of ST/T changes in serial ECG Lab tests on the next day: -cardiac enzymes in normal range -serum creatinine 1.2 mg% Lab tests on the next day: -cardiac enzymes in normal range -serum creatinine 1.2 mg% Hospital stay:36 hours Hospital stay:36 hours

13. Discussion: Symptoms suggesting renal artery stenosis (RAS) in the presented patient: Symptoms suggesting renal artery stenosis (RAS) in the presented patient: -short history of hypertension -diastolic hypertension resisted to pharmacological treatment -the history of pulmonary oedema despite of preserved global LVEF -short history of hypertension -diastolic hypertension resisted to pharmacological treatment -the history of pulmonary oedema despite of preserved global LVEF

14. CAD & RAS In 15% of patients undergoing CAG, a significant RAS (>50%) can be found No of narrowed Risk coronary arteriesof RAS 08.8% 110.7% 217.6% 329,9% LM39.0% In 15% of patients undergoing CAG, a significant RAS (>50%) can be found No of narrowed Risk coronary arteriesof RAS 08.8% 110.7% 217.6% 329,9% LM39.0% (The Duke University Experience)

15. RAS & Risk of MACE AMI AMI Revascularization (PTCA or CABG) Revascularization (PTCA or CABG) No-RASRASp 13.8%41%0.01 33.1%58.3%0.01 (The Duke University Experience)

16. The influence of renal stenting on UA and CHF N=48 pts with UA or CHF and concomitant uni- or bilateral RAS Results: After renal stenting resolution of symptoms in 88% of patients during 8.4 months follow-up. Am J Cardiol 1997;80:363-6

17. Influence of renal stenting on renal function Circulation 1998;98:642-7 months

18. Conclusions: Patients with angina and the history suggesting RAS, coronary angiography should be always followed by renal artery angiography. Patients with angina and the history suggesting RAS, coronary angiography should be always followed by renal artery angiography. Renal artery angiography and renal stenting can be performed easily during CAG or PCI as a one stage procedure at the low risk and low additional cost. Renal artery angiography and renal stenting can be performed easily during CAG or PCI as a one stage procedure at the low risk and low additional cost.