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Coronary Arteries
- 1. Coronary ArteriesThe Basicsand Beyond
- 2. Function of coronaryarteries: delivery of oxygenated blood to the heart muscle (myocardium)The VERY BasicsHow-to-draw-cartoons-online.com
- 3. Left coronary artery: arises from the left coronary sinus/cusp of the Aortic valveLeft main artery branches into:LAD- Left Anterior Descending CX- CircumflexRight coronary artery: arises from the right coronary sinus/cusp of the Aortic valveMain Branches
- 4. Coronary arteries lieon top of the myocardium (epicardial) and follow the Atrioventricular (AV) groove and the Interventricular (IV) grooveCX courses along AV grooveLAD and distal RCA follow IV grooveBasics, cont
- 5.
- 6. LAD: diagonalsand septalsCX: obtuse marginals, occasionally Posterior descending artery (PDA)RCA: acute marginals, Posterior lateral artery (PLA), and PDARamusintermedius: arises between LAD and CX in 5%-10% of populationMajor Branches
- 7. A person canbe “right dominant”, “left dominant”, or “co-dominant”.This depends on which artery (or arteries) give rise to the PDA and PLA, which run along the posterior side of the heart.Coronary Dominance
- 8. Right DominantThe PDAbranch arises from the RCA (60%-70% of population)
- 9. Left DominantThe PDAarises from the LCA (10%-15% of population)
- 10. RCA gives riseto the PDA and then ends, while the CX supplies the PLA branchesCX may also supply a left PDA that runs parallel to the right PDACo-Dominant
- 11. As with allstructures in the human body, WEIRD stuff can happen! A few examples:CX originates with RCA from right sinusLM from right sinusRCA from left sinusSeparate originations (ostia) for all threeAll three arteries from one ostiaVariations and Anomalies
- 12. Coronary aneurysmsFistulas- abnormalcommunication with venous systemAnomalous 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)Anomalies
- 13. Adventitia- outermost, connectivetissue covering the vesselMedia- smooth muscle cellsSpasm- contraction of cells causing disturbance of blood flow (caused by numerous factors: caffeine or stimulant induced, catheter induced)Intima- innermost, single layer of cellsAnatomy of an Artery
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- 16. LAD supplies: most of septum, anterior/lateral/apical LV, anterolateral pap muscleCX supplies: LA, posterior/lateral LV, anterolateral pap muscle, SA node (45%), AV node (10%), septum, His bundle, posterior pap muscle, inferoposterior LVRCA supplies: SA node (55%), RA, AV node (90%), septum, His bundle, posterior pap muscle, inferoposterior LVMyocardial Blood Supply
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- 18. Coronary Arteries perfusein diastole (this is part of the theory behind the IABP)Coronary sinus collects used blood from the mycardium to send to lungs for re-oxygenationCoronary bridging = compression of a coronary artery by the myocardium during systoleUsually benign, but can occasionally result in MI or even death (most common with LAD)Hemodynamics
- 19. Several medications areinjected to elicit vasodilation in the arteries during catheterization, such as diltiazem, verapamil, adenosine, nitroglycerine, and niprideIIbIIIa Inhibitors (abciximab, eptifibitide) are also directly injected in coronary arteries with apparent thrombusPharmacology
- 20. CAD and Atherosclerosis: What does this mean, exactly?Build-up of fatty substances, cholesterol, cellular waste products, and calcium within the intima of an arteryWith or without symptomsCoronary Artery Disease
- 21.
- 22. Rupture of fibrouscapPlatelets rush in to fix the vesselClot formsBlood flow obstructedDamage/death of myocardiumPathophysiology of Acute MI
- 23. Many tests andscreening tools are available to help detect CADCan be invasive or non-invasiveCan be performed in MD’s office or hospital, depending on type of testDiagnostic Testing Methods
- 24. Treadmill- assesses coronaryblood flow by ECG, blood pressure, and signs/symptoms during exerciseStress Tests
- 26. Stress Echocardiogram-compares LVwall motion at rest and under stressUsed for low-moderate risk patients and younger patients where there may be structural/valvular/congenital causes of symptomsStress TestsJohnson.com
- 27. Perfusion scan- comparesblood flow at rest and under stress by imaging the myocardium after a radioactive tracer is injectedStress TestsBocacardiology.com
- 28. Echocardiogram- assesses structural,valvular, and congenital causes of heart diseaseDiagnostic TestingBrighamandwomens.org
- 29. Cardiac MRI- usefulfor diagnosis of structural disease (cardiomyopathy, masses) with or without contrastGold standard for congenital heart diseaseDiagnostic Testing
- 30. Cardiac Computed Tomography(CT)-evaluates coronary arteries as well as LV function, anatomy, and calcification (calcium score)Diagnostic TestingImagingeconomics.com
- 31.
- 32. Coronary Angiography- usedfor positive and indeterminate stress tests, assessment of bypass graftsAlso for patients with known history of CADGold standard for coronary evaluationDiagnostic TestingCirculation.or.kr
- 33. IVUS- small ultrasoundcatheter is inserted in the coronary artery to image the vessel and assess plaqueCan differentiate between fibrous and calcified plaqueVirtual histologyDiagnostic TestingIntravascular UltrasoundPtca.org
- 34. Technically: the ratioof blood flow in a stenotic artery to normal flowEssentially: a stress test on a specific arteryFlow is measured by a special guidewire, using flow measurements beyond the lesion and comparing them with flow before the lesionIV infusion of Adenosine is used to increase HR Ratio is calculated from a 2-3 minute periodNormal value = 1.0Abnormal value = <0.75Diagnostic TestingFractional Flow Reserve (FFR)
- 35. Treatment of CADMedicaltreatment- managing the patient’s medications to help alleviate symptomsPercutaneous Coronary Intervention (PCI)- used in various situations, from single lesions to complex, high-risk multi vessel disease
- 36.
- 37. Treatment of CADCoronaryArtery Bypass Grafting- most often used for severe multi vessel disease and diabetic patientsBeaumonthospitals.com
- 38. We’ve come along way from the first accidental coronary angiogram in 1958…Diagnosis and treatments continue to evolveCoronary Arteries Summary
- 39. Peripheral Arterial Disease(PAD)Same arterial anatomy and disease process, but most patients (with exception of CVA) tend to wait much longer to seek treatmentMay mimic arthritis, neuropathySymptoms attributed to “old age”What about Peripheral Vascular Disease?
- 40. Claudication- leg painwith walking that resolves at restDecreased temperature of extremityNon-healing woundsSymptoms of LE PAD
- 41. Sudden numbness orweakness, especially on one sideSudden confusion, trouble speakingSudden trouble seeingin one or both eyesSudden dizziness, loss of balance and coordinationSudden severe headacheSymptoms of CVA
- 42.
- 43. MedicationsPercutaneousTransluminal Angioplasty (PTA)with or without stent placementAtherectomyBypass surgeryTreatment of PAD
- 44. Interventions done forhigh-risk, asymptomatic or symptomatic patients (depends on clinical study enrollment)All patients must be enrolled in a research study to receive a stentTypical 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 locationCarotids
- 45. Cleveland Clinic Heartand Vascular Institute
- 46. Code StrokeAn Interdisciplinaryeffort to get treatment started for stroke victims ASAPEmcompasses: ED assessment, activation of Code Stroke protocol, Neurology consults, CT scans, Interventional Cardiology consults, thrombolytic treatment if indicated, invasive intervention if indicated
- 47. RenalsInterventions performed forpoorly controlled hypertension or poor renal functionRivascularinstitute.com
- 48. Interventions performed forclaudication, critical limb ischemia (non healing wounds), and limb salvageLower Extremity
- 49.
- 50. PADBasically, if wecan get a catheter to an artery, we can take a picture and potentially intervene!MesentericsSubclaviansETC…
- 51. Fast growing segmentof cardiac cath lab proceduresPercutaneous treatments are constantly being developedPAD Summary
- 52. Cvphysiology.comHeartsite.comNEJM, Vol. 360No.3Ncbi.nlm.nih.govEncyclopedia BrittanicaMed.yale.eduJohnson.comBocacardiology.comBrighamandwomens.orgNature Publishing GroupEmedicine.medscape.comSources
- 53. 64ctscan.comCsmc.eduCirculation.or.krPtca.orgBeaumonthospitals.comNhlbi.nih.govCleveland Clinic Heartand Vascular InstituteRivascularinstitute.comRadiologyrsnajnls.orgImagingeconomics.comHow-to-draw-cartoons-online.comSources
Editor's Notes
- #4Â 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).
- #8 Those in the cath lab know this from ACC database…
- #12 The one that seems most common is the first example…
- #13 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…(emedicine.medscape.com)
- #17 Knowledge of myocardial blood supply comes in handy when interpreting an ECG…
- #18 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…
- #19 An IABP inflates during diastole, which will push more blood down the coronaries when the LV has been damaged…
- #20 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.
- #24Â How do we find as many of these people as possible before the MI happens?
- #36Â So, what are the options for a patient with significant CAD?
- #39 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…