BRAUNWALD

CHAPTER 54

Chronic Coronary Artery Disease

 Index
Magnitude of the Problem,
Stable Angina Pectoris,: Noninvasive
Testing,
Risk Stratification,
Medical Management,
Percutaneous Coronary
Intervention,
Coronary Artery Bypass Surgery,
Other Manifestations of Coronary
Artery Disease,
 Coronary Epidemic
It is estimated that 13,200,000 Americans
have CAD, 6,500,00 of whom have angina
pectoris and 7,200,000 have had
myocardial infarction.
Lifetime risk : after age 40, is 49% men
and 32% for women. (FHS)
The single most frequent cause of death in
men and women, resulting in more than
one in five deaths in the United States.
Cost in 2006 has been estimated at
$142.5 billion.
 Angina
Angina pectoris is a discomfort in
the chest or adjacent areas caused
by myocardial ischemia.
Heberden's initial description of
angina as conveying a sense of
“strangling and anxiety” is still
remarkably pertinent.
Begins gradually and reaches its
maximum intensity over a period of
minutes before dissipating.
Dyspnea at rest or with exertion may
be a manifestation of severe
ischemia, leading to increases in left
ventricular (LV) filling pressure.
Nocturnal angina should raise the
suspicion of sleep apnea
Esophageal pain and other
syndromes may also respond to
nitroglycerin.
A delay of more than 5 to 10 minutes
before relief is obtained by rest and
nitroglycerin suggests that the
symptoms are either not caused by
ischemia or are caused by severe
ischemia,
Fi rst- eff ort or wa rm- up
angina
Angina develops with exertion but pt can
continue subsequently at the same or
even greater level of exertion without
symptoms after an intervening period of
rest.
Postulated to be caused by ischemic
preconditioning and appears to require
preceding ischemia of at least moderate
intensity to induce the warm-up
phenomenon.
 The Canadian Card io vascula r
Socie ty A ngin a Gr adin g Sc ale

Class I – Angina only during strenuous

or prolonged physical activity
Class II – Slight limitation, with angina
only during vigorous physical activity
Class III – Symptoms with everyday
living activities, i.e., moderate limitation
Class IV – Inability to perform any
activity without angina or angina at rest,
i.e., severe limitation
 Mechanism
Chemosensitive and mechanoreceptive
receptors in the heart.
Adenosine, bradykinin, and other substances
excite the sensory ends of the sympathetic
and vagal afferent fibers possibly through
vanilloid receptor-1 :VR1
PET of the brain in silent ischemia suggested
that failed transmission of signals from the
thalamus to the frontal cortex may contribute
to this phenomenon along with autonomic
neuropathy.
FIX ED-THR ESHOL D COMPA RED
WIT H V ARIA BLE-T HR ESH OL D
ANGIN A.

Fixed: The level of physical activity/ double

product required to precipitate angina is
relatively constant.
Variable: Have coronary arterial narrowing,
but dynamic obstruction caused by
vasoconstriction plays an important role in
causing myocardial ischemia.
Postprandial angina may be a marker of
severe multivessel CAD.
Mixed
 Physical Exam

Single best clue to the diagnosis of

angina is the clinical history.
Corneal arcus and xanthomas
Retinal arteriolar changes
Blood pressure/ ABI
MR during an episode of pain with a
third heart sound
Massage of the carotid sinus.
 Biomarkers
Hypercholesterolemia
Insulin resistance
Lipoprotein(a)
Apoprotein B, small dense LDLs,
Lipoprotein-associated phospholipase
A2 (Lp-PLA2)
Homocysteine
hsCRP
Troponin, BNP and N-terminal pro-BNP
 ECG
The resting ECG is normal in approximately
half of patients with chronic stable angina
pectoris, and even patients with severe CAD
may have a normal tracing at rest.
The most common electrocardiographic
abnormalities in patients with chronic CAD
are nonspecific ST-T wave changes
EKG becomes abnormal in an episode of
angina pectoris in 50 percent
Many patients with symptomatic myocardial
ischemia also have episodes of silent
ischemia
 Stress testing
Bayesian principle, states that the
reliability and predictive accuracy of any
test are defined not only by its
sensitivity and specificity but also by the
prevalence of disease (or pretest
probability) in the population under
study.
A reasonable estimate of the pretest
probability of CAD may be made on
clinical grounds.
 Exercise EKG

Done in intermediate probability

Negative exercise test result in
patients receiving antianginal drugs
does not exclude significant and
possibly severe CAD.
Should be performed, if possible, in
the absence of antianginal
medications.
 Nuclear
Exercise perfusion imaging with simultaneous
electrocardiographic testing is superior to
exercise electrocardiography
SPECT yields an average sensitivity and
specificity of 88 and 72 percent, respectively
compared with 68 percent sensitivity and 77
percent specificity for exercise
electrocardiography
Valuable for detecting myocardial viability in
patients with regional or global LV dysfunction
TABL E 54-2   -- Sensitiv ity
and Specificity o f Str ess
Tes ting
Modality Sensitivity Specificity
Exercise ECG 0.68 0.77
Exercise SPECT 0.88 0.72
Adenosine SPECT 0.90 0.82
Exercise echo 0.85 0.81
Dobut echo 0.81 0.79
Treadmill testing is preferred for patients
who are capable of exercising because the
exercise component of the test provides
additional diagnostic and prognostic
information, including ST segment
changes, effort tolerance and
symptomatic response, and heart rate and
blood pressure response.
Exercise echo: localizing and quantifying
ischemic myocardium. Also provides
important prognostic information about
patients with known or suspected CAD
 Men vs Women
Once men and women are stratified
appropriately according to the
pretest prevalence of disease, the
results of stress testing are similar,
although the specificity is probably
slightly less in women.
Exercise imaging modalities have
greater diagnostic accuracy than
exercise electrocardiography in men
and women.
 High risk findings
1. Severe resting left ventricular dysfunction (EF < 0.35)
2. High-risk treadmill score (score ≤ -11)
3. Severe exercise left ventricular dysfunction (exercise
LVEF < 0.35)
4. Stress-induced large or multiple perfusion defects
(particularly if anterior)
5. Large, fixed perfusion defect with LV dilation or
increased lung uptake (thallium-201)
6. Stress-induced moderate perfusion defect with LV
dilation or increased lung uptake (thallium-201)
7. Echocardiographic wall motion abnormality (involving
more than two segments) developing at low dose of
dobutamine (≤10 μg/kg/min) or at a low heart rate (<120
beats/min)
 Cardiac CT
The calcium score is a quantitative index
of total coronary artery calcium detected
by CT, and this score has been shown to
be a good marker of the total coronary
atherosclerotic burden.
Highly sensitive (approximately 90
percent) finding in patients who have
CAD, the specificity for identifying
patients with obstructive CAD is low
(approximately 50 percent).
 Cardiac MRI
Pharmacological stress perfusion
imaging with CMR also compares
favorably with other methods
Myocardial viability assessment is
growing based its ability to predict
functional recovery after
revascularization and its very good
correlation with PET.
Can characterize arterial atheroma
and assess vulnerability to rupture.
 Stress testing in
asymtomatic persons
with no previous CAD?

Diabetics who are planning vigorous

exercise.
EKG changes on Holter
Severe coronary calcification.
 Cath
Approximately 25 percent each have
single-, double-, or triple-vessel
disease (i.e., more than 70 percent
narrowing). 5 to 10 percent have
obstruction of the left main coronary
artery and in 15 percent, no critical
obstruction is detectable.
Coronary angiography and IVUS
Post MI are less severe
 Findings: ECTASI A AN D
AN EU RYSMS :
1 to 3 percent of patients with obstructive
CAD
Caused by coronary atherosclerosis (50
percent), congenital anomalies and
inflammatory diseases such as Kawasaki
disease.
There is cardiac ischemia based on
cardiac lactate levels during ergometry
and atrial pacing.
Coronary ectasia should be distinguished
from discrete coronary artery aneurysms
 MY OCAR DI AL
BRI DG IN G
Less than 5 % in otherwise normal
coronary arteries and ordinarily does not
constitute a hazard
Can be associated with clinical
manifestations of myocardial ischemia
during strenuous physical activity and
may even result in myocardial infarction or
initiate malignant ventricular arrhythmias.
 LV Function
LV function can be assessed by
means of biplane contrast
ventriculography .
LV end-diastolic and end-systolic
volumes
Abnormalities of regional wall
motion (e.g., hypokinesis, akinesia,
dyskinesia)
Diastolic filling and LV end-diastolic
pressure
 MY OCAR DI AL
META BOL ISM
Lactate measurements are obtained
at rest and after suitable stress, such
as the infusion of isoproterenol or
pacing-induced tachycardia.
Studies of coronary flow reserve and
endothelial function are frequently
abnormal in patients with CAD and
microvascular disease.
FIG UR E 5 4- 2 N omo gr am s how ing the pr oba bi lit y of
sev ere (t ripl e-v essel or le ft ma in) cor ona ry ar tery
di sea se b ase d o n a f iv e-p oin t c li nic al sco re
as sign ed on th e b asis of c li nic al var iab le s: mal e
ge nd er, typi cal a ngi na , h is tory an d
elec troca rdi og raph ic ev ide nce o f my oc ar dia l
inf ar ctio n, an d d ia bet es
Prognosis based on cath
High-grade lesions of the left main coronary artery or
its equivalent, as defined by severe proximal left
anterior descending and proximal left circumflex
CAD, are particularly life-threatening. Mortality in
medically treated patients has been reported to be 29
percent at 18 months and 43 percent at 5 years.
Survival is better for patients with 50 to 70 percent
stenosis.
Predictors of an adverse prognosis in patients with 70
percent or more left main coronary artery stenosis,
include chest pain at rest, ST-T wave changes on the
resting ECG, cardiomegaly or LVD
EF 35 to
50%
 Limitations of cath
Coronary angiography is not a reliable
indicator of the functional significance of
stenosis.
The severity of stenosis are based on a
decrease in the caliber of the lumen at
the site of the lesion relative to adjacent
reference segments
Inability to identify which coronary
lesions can be considered to be at high
risk, or vulnerable.
Medical Management

(1) Identification and treatment of

associated diseases that can
precipitate or worsen angina;
(2) Reduction of coronary risk
factors;
(3) Adjustments in life style;
(4) Pharmacological management;
(5) Revascularization
 HTN
For individuals aged 40 to 70 years,
the risk of ischemic heart disease
doubles for each 20–mm Hg
increment in systolic blood pressure
across the entire range of 115 to 185
mm Hg.
LV hypertrophy is a stronger
predictor of myocardial infarction
and CAD death
 Smoking
Worsens atherosclerosis
It may increase myocardial O2 demand and
reduce coronary blood flow by means of an
alpha-adrenergically mediated increase in
coronary artery tone and thereby cause acute
ischemia.
Smoking cessation is one of the most effective
and certainly the least expensive approach to the
prevention of disease progression i
 Diabetes
During a mean follow-up of 17 years in
participants in the DCCT (Diabetes Control
and Complications Trial), patients with type 1
diabetes with intensive therapy were at lower
risk of cardiovascular complications.
In an analysis of a secondary endpoint of the
Prospective Pioglitazone Clinical Trial in
Macrovascular Events Trial (PROACTIVE),
treatment of patients with type 2 diabetes with
the oral hypoglycemic agent pioglitazone
reduced the risk of death, non-fatal MI, or
stroke
 Exercise
9 small randomized studies with a total
of 980 patients
Improved effort tolerance,
O2 consumption,
quality of life and well being
Improves morphology of obstructive
lesions and endothelial function.
Avoid Isometric activities that involve an
energy expenditure between 60 and 65
percent of peak oxygen consumption.
Avoid sudden bursts of activity,
particularly after long periods of rest,
after meals, and in cold weather.
Eliminating or reducing the factors that
precipitate anginal episodes
Morning activities such as showering,
shaving, and dressing should be done
at a slower pace and, if necessary, with
the use of prophylactic nitroglycerin.
Avoid lifting weights, snow shoveling,
and cross-country or downhill skiing
 Lifestyle
HRT : Not to be initiated or continued for secondary
cardiovascular prevention in women with CAD.
There is no basis for recommending that individuals
take supplemental folate, vitamin E, vitamin C, or
beta-carotene for the purpose of treating CAD.
Association between depressive symptoms and CAD
may reflect a causal relationship between the former
and atherothrombosis. Depressive symptoms are
associated with higher levels of circulating
biomarkers of inflammation.
 Preventive meds

Aspirin 75 to 162 mg daily is preferred

for secondary prevention in the
absence of recent intracoronary
stenting. (RRR 35 to 87% during 5
years).
Although warfarin has proved beneficial
in patients after MI, no evidence
supports the use of chronic
anticoagulation in patients with stable
 Plavix
Use Plavix when ASA allergy
Clopidogrel versus Aspirin in Patients at Risk of
Ischaemic Events [CAPRIE] 8.7 percent relative
reduction in the risk of vascular death, ischemic
stroke, or myocardial infarction over 2 years.
Clopidogrel for High Atherothrombotic Risk and
Ischemic Stabilization Management and Avoidance
(CHARISMA) trial has shown no overall benefit of the
addition of clopidogrel to aspirin with respect to the
primary endpoint of cardiovascular death, MI, or
stroke over a median of 28 months
Subgroup analyses from the trial have demonstrated
a 1 percent lower risk for those with established
vascular disease
 Antiinflammatory
Cholesterol and Recurrent Events (CARE) trial and
the Air Force/Texas Coronary Atherosclerosis
Prevention Study (AFCAPS/TexCAPS) are among
the many studies that have demonstrated lowering of
circulating levels of hsCRP after treatment with
statins.
Statins are effective in modifying the risk associated
with evidence of systemic inflammation and that
inflammatory markers may complement LDL
measurement in monitoring the efficacy of statin
therapy.
Aspirin, ACE inhibitors, thiazolidinediones,
thienopyridines, and fibric acid derivatives
 Beta blockers
Shown to reduce mortality and reinfarction in
Post MI and to reduce mortality in patients
with heart failure.
Decreases anginal episodes
Use in preventing infarction and sudden
death in patients with chronic stable angina
without previous infarction is uncertain and,
despite at least one observational study
suggesting lower mortality in the patients who
were taking beta blockers, there have been
no controlled trials against placebo.
Lipid-soluble agents (propranolol,
metoprolol, and pindolol) are often
preferable in patients with significant
renal dysfunction
Greater lipid solubility is associated with
greater penetration to the central
nervous system and may contribute to
side effects (e.g., lethargy, depression,
hallucinations)
metoprolol, carvedilol, and propranolol
may be influenced by genetic
polymorphisms or other medications
Ideal Candidates for beta blocker

Prominent relationship of physical

activity to attacks of angina
Coexistent hypertension
History of arrhythmias
Previous myocardial infarction
Left ventricular systolic dysfunction
Mild to moderate heart failure
symptoms (NYHA II, III)
Prominent anxiety state
The resting heart rate should be
reduced to between 50 and 60
beats/min, and an increase of less than
20 beats/min should occur with modest
exercise (e.g., climbing one flight of
stairs).
In patients with symptomatic conduction
disease, beta blockers are
contraindicated unless a pacemaker is
in place
 CCB
Dihydropyridines (nifedipine is the
prototype), t
Phenylalkylamines (verapamil is the
prototype),
Benzothiazepines (diltiazem is the
prototype).
The two predominant effects are blocking the
entry of calcium ions and slowing recovery of
the channel.
Reduction in myocardial O2 demand
and the increase in O2 supply
Calcium antagonists may have some
role in atheroprotection
Dihydropyridines do not impair channel
recovery
Verapamil is contraindicated for
patients with preexisting AV nodal
disease or sick sinus syndrome,
congestive heart failure, and suspected
digitalis or quinidine toxicity.
 Adverse Effects

15 to 20 percent of patients
Headache, dizziness, palpitations,
flushing, hypotension, and leg edema
In patients with extremely severe fixed
coronary obstructions, nifedipine
aggravates angina and so it should be
combined with beta blocker and
sustained released used.
 Diltiazem
Atenolol and diltiazem have similar
efficacy in increasing nonischemic
exercise duration in patients with
variable-threshold angina and act
primarily by slowing the resting heart
rate.
High doses (mean dose, 340 mg) have
been shown to be a relatively safe and
cause increases in exercise tolerance
and resting and exercise LV ejection
fractions
 Amlodipine

Amlodipine has little, if any, negative

inotropic action and may be especially
useful in patients with chronic angina
and LV dysfunction
In two trials in patients with established
CAD, amlodipine reduced the risk of
major cardiovascular events
Nicardipine may be used as an
antianginal and antihypertensive agent
for chronic stable angina pectoris,
It appears to be as effective as
verapamil or diltiazem,
Felodipine has also been reported to be
more vascular selective than nifedipine
and to have a mild positive inotropic
effect
 Ranolazine
Ranolazine is a piperazine derivative
that was approved in 2006 in the United
States for use in patients with chronic
stable angina in conjunction with beta
blockers, calcium antagonists, or
nitrates.
Reduces in calcium overload in the
ischemic myocyte via inhibition of the
late sodium current (INa). And preserves
ATP levels.
Ranolazine is contraindicated in
patients with preexisting QT
prolongation, receiving other QT-
prolonging medications, or with hepatic
impairment
Metabolized primarily through the
cytochrome P-450
3 RCTs show improved exercise
performance and increased the time to
ischemia
 Nicorandil
Dilates peripheral and coronary
resistance vessels via action on ATP-
sensitive potassium channels and
possesses a nitrate moiety that
promotes systemic venous and
coronary vasodilation
Reduces preload and afterload
May have cardioprotective actions
mediated through the activation of
potassium channels.
 Fasudil

Fasudil is an orally available inhibitor of

rho kinase, an intracellular signaling
molecule that participates in vascular
smooth muscle contraction.
Fasudil was shown to increase the time
to ischemia
 Nitrates
Nitrates improve exercise tolerance and time
to ST segment depression during treadmill
exercise tests. When used in combination
with calcium-channel blockers and/or beta
blockers, the antianginal effects appear
greater
Nitroglycerin causes redistribution of blood
flow from normally perfused to ischemic
areas, particularly in the subendocardium
Inhibitory action on platelets
Nitrate mechanism
 Tolerance

1) Plasma volume expansion and

neurohormonal activation;
(2) Impaired biotransformation of
nitrates to NO; and
(3) Decreased end-organ
responsiveness to NO.
12-hour off-period is recommended.
 Adverse Effects
Headache, flushing, and hypotension.
In some patients with volume depletion
and in an upright posture, nitrate-
induced hypotension is accompanied by
a paradoxical bradycardia, consistent
with a vasovagal or vasodepressor
response.
Ventilation-perfusion imbalance
Methemoglobinemia
ACEI
 Summary
In stable patients with LV
dysfunction following myocardial
infarction, evidence has consistently
indicated that ACE inhibitors and
beta blockers reduce both mortality
and the risk of repeat infarction, and
these agents are recommended in
such patients, with or without
chronic angina, along with aspirin
and lipid-lowering drugs
 An gin a a nd
prese rve d L V
functio n.
Reduce mortality and morbidity:
aspirin, angiotensin-converting
enzyme [ACE] inhibition, and
effective lipid lowering
Improve symptomatology :
nitrates, beta blockers, and calcium
antagonists
 Cord Stimulation

Used for refractory angina who are not

candidates for coronary revascularization
using a specially designed electrode inserted
into the epidural space.
In a small randomized trial in patients with
angina and CAD not amenable to PCI, spinal
cord stimulation was associated with similar
symptom relief and long-term quality of life
compared with CABG.
 EN HAN CED EXTERN AL
CO UNTERPU LSATI ON

EECP is generally administered as 35

1-hour treatments over 7 weeks.
EECP reduces the frequency of angina
and the use of nitroglycerin and
improves exercise tolerance and quality
of life, and that the responses can last
for up to 2 years
Increases in time to ST-segment
depression during exercise testing
 Mechanisms
1) Durable hemodynamic changes that
reduce myocardial O2 demand;
(2) Improvement in myocardial
perfusion caused by the capacity of
increased transmyocardial pressure to
open collaterals; and
(3) The elaboration of various
substances that improve endothelial
function and vascular remodeling
 PCI

Patients with chronic stable angina who

are ideal for PCI are those with
significant symptoms despite intensive
medical therapy, who are at low risk for
complications, and in whom the
likelihood of technical success is high—
no history of congestive heart failure
and an ejection fraction greater than 40
percent.
 PCI

Overall procedural success rate of at

least 90 percent with a mortality of less
than 1 percent, rate of Q wave
myocardial infarction of less than 1.5
percent, and rate of emergency bypass
surgery of 1 to 2 percent.
PCI : Poor outcome in

Advanced age, female gender, unstable

angina, congestive heart failure, left
main coronary artery–equivalent
disease, and multivessel CAD.
Diabetes mellitus
Impaired renal function, particularly
those with diabetes,
 Clinical Outcomes Uti liz ati on
Revas cul ar iz ati on and Aggressi ve D ruG
Evaluati on (COUR AGE) tri al
 PCI
No randomized trial to date has demonstrated
a reduction in death or myocardial infarction
with PCI compared with medical therapy for
patients with chronic stable angina.
It appears reasonable to pursue a strategy of
initial medical therapy chronic stable angina
and CCS class I or II symptoms and to
reserve revascularization for those with
persistent and/or more severe symptoms or
those with high-risk criteria on noninvasive
testing, such as inducible ischemia involving
a moderate or large territory of myocardium
 CABG
In 1964, Garrett, Dennis, and DeBakey
first used CABG as a “bailout”
procedure
Use of the internal mammary artery (IMA)
graft was pioneered by Kolessov in
1967 and by Green and colleagues in
1970.
In 2003, approximately 268,000 patients
underwent coronary bypass surgery; a
decline of 26 percent since 1997
Minimally invasive CABG
• Port access CABG
• Off-pump CABG
• Minimally invasive direct coronary artery
bypass (MIDCAB)
The avoidance of CPB may mitigate the
risk of bleeding, systemic
thromboembolism, renal insufficiency,
myocardial stunning, stroke, and
damaging neurological effects of
bypass, particularly in the elderly and in
patients with heavily calcified aortas.
 Port Access CABG
Uses small thoracotomy ports for
cardiac manipulation; CPB is
established by groin cannulation
(femoral-femoral CPB and cardioplegic
arrest.) and an intraaortic balloon
clamp for occlusion of the aorta.
Data comparing port access with
traditional CABG are few but have
indicated similar short-term
outcomes
 OF F-PU MP CAB G.
Performed using a standard median
sternotomy, with generally small skin
incisions, and stabilization devices
Has comparable completeness of
revascularization, reductions in blood
loss, fewer wound infections, less
postoperative atrial fibrillation, lower
indices of myocardial injury, shorter
duration of mechanical ventilation, and
earlier hospital discharge with OPCAB
 MINIM ALLY I NVASI VE
DI RECT CABG .
Limited left thoracotomy on the beating
heart (off-pump), most commonly with
grafting of the LIMA to LAD.
Operation be generally limited to
revascularization of the LAD because of
lesser accessibility of the left circumflex
and right coronary arteries.
Can be used with revascularization of
other diseased arteries by PCI.
 Cardioplegia

Cold crystalloid / Blood cardioplegia

Metabolic substrates:
sodium-hydrogen exchange
inhibitors,
l-arginine, insulin, or adenosine
Acadesine
 Saphenous vein
The saphenous vein is used mainly for distal
branches of the right and circumflex coronary
arteries and for sequential grafts to these
vessels and diagonal branches
The saphenous vein can be harvested and
grafted more rapidly.
Endoscopic harvesting
Aortic-saphenous vein graft connectors –
more stenosis.
 IMA
Appears to be virtually immune to the
development of intimal hyperplasia, and the
functional capacity of the artery remains
intact.
The current standard for bypass grafting
advocates routine use of the left IMA for
grafting the LAD coronary artery
Bilateral IMA grafting is associated with lower
rates of recurrent angina pectoris,
reoperation, and myocardial infarction and
improved survival.
 Other conduits
Radial arterial grafts may be associated with
fewer complications and thus are preferable
to the right IMA as a second arterial graft.
A randomized trial comparing usual grafting
with total arterial revascularization detected
no differences postoperative complications
but at a mean follow-up of 12 months, were
less likely to have recurrent angina or to
require additional revascularization.
The right gastroepiploic artery.
Bovine IMA, Dacron, and PTFE grafts have
lower patency (50 to 60 percent)
Late patency of grafts is related to coronary
arterial runoff as determined by the diameter
of the coronary artery (1.5 mm) into which the
graft is inserted, size of the distal vascular
bed, and severity of coronary atherosclerosis
distal to the site of insertion of the graft.
Over the years the CABG population has
been older and with more complex disease
but despite the increasing risk profile of this
population, outcomes have generally
remained stable or have improved.
 CABG: Mortality
Despite a shift toward higher risk
demographics, early mortality continued to
decline in the 1990s from 3.05 to 2.2 percent
There is even greater decline in CABG
mortality over the past decade when adjusted
for changes in risk profile
Perioperative morbidity with major
complications has increased (13.4 percent
through 30 days ) because of a larger fraction
of higher risk patients.
 Post Op MI
Incidence of post op MI is 3.9 percent.
CK-MB more than five times the upper limit of
normal is diagnostic of myocardial infarction
in this setting and is associated with mortality.
Coronary Artery Surgery Study (CASS)
predictors: female gender, severe
perioperative angina pectoris, severe
stenosis of the left main coronary artery, and
triple-vessel disease.
 Pulm. Complications
Prolonged mechanical ventilation (longer than
24 hours) is necessary in 5 to 6 percent of
first-time CABGs and 10 to 11 percent of
reoperations
The cause is multifactorial and includes the
presence of preexisting pulmonary disease
and numerous perioperative factors
The LV ejection fraction is also an important
determinant of prolonged ventilation
 Bleeding
Reoperation for bleeding is required in 2 to 6
percent of patients and is associated with a
nearly threefold higher in-hospital mortality.
Bleeding may be reduced with aprotinin and
lysine analogues, such as aminocaproic acid
and tranexamic acid.
Use of clopidogrel within 5 days of CABG and
prolonged CPB are important risk factors
Wound Complications

Mediastinitis and/or wound dehiscence, occur

in 1 to 4 percent of patients and are
associated with significant morbidity as well
as higher mortality.
This risk is substantially increased in those
undergoing reoperation and by the use of
double IMA grafts, particularly in diabetic
patients, and is markedly increased in obese
patients.
 Neurological
Cause: emboli from the aorta or other large
arteries, the CPB circuit, and intraoperative
hypotension,
Type I injury is associated with major
neurological deficits, stupor, and coma, and
type II injury is characterized by a
deterioration in intellectual function and
memory.
Sophisticated neurocognitive testing revealed
cognitive decline in 53 percent of patients at
the time of hospital discharge.
 Risk Factors
Older Age
Diabetes
Intraoperative manipulation of the aorta
Atherosclerosis of the proximal aorta
The use of an intraaortic balloon pump.
Mild hypothermia in the intra- and
perioperative periods may improve
neurocognitive function after CABG.
 A. Fib
Occurs in up to 40 percent of patients
May compromise systemic hemodynamics,
increase the risk of embolization, and lead to
a significant increase in the duration and cost
of the hospital stay, and it is associated with a
twofold to threefold increase in postoperative
stroke.
Prior statin, B blocker, Amio reduces the
frequency.
 Renal Failure
Low risk (0.5 to 1.0 percent) but is associated
with significantly greater morbidity and
mortality.
A decline in renal function defined by a
postoperative serum creatinine level higher
than 2.0 mg/dl or an increase of more than
0.7 mg/dl.
A randomized trial of N-acetylcysteine
showed no difference compared with placebo.
 Return to full
employment
Has been variable (35 to 80 percent)
Patients who undergo CABG take 6
weeks longer to return to work than
those who are treated with PCI
However, long-term employment is
similar (more than 80 percent) in
patients treated with CABG or PCI.
 Patency
Early occlusion : 8 to 12
1 year, : 15 to 30.
2-5 yrs : 2 percent / yr
6 to 10 yrs: 4 percent /yr
At 10 years : 50 percent of vein grafts have
become occluded
IMA grafts had patency rates of 95, 88, and
83 percent at 1, 5, and 10 years, respectively.
CABG vs. PCI
 CABG vs. PCI
When an unacceptable level of angina
persists despite medical management, and/or
exhibits a high-risk result on noninvasive
testing, the coronary anatomy should be
defined.
The choice between PCI and CABG will likely
revolve around the ability of each procedure
to achieve complete revascularization in any
given patient.
Patients with more extensive and severe CAD
have an increasing magnitude of benefit from
CABG over medical therapy
Duke
database
5 yr
mortality
Single vessel: PCI
LM or triple vessel ; CABG
Other multivessel: PCI is a reasonable
initial strategy, provided that the patient
accepts the distinct possibility of
symptom recurrence and need for
repeat revascularization. Patients with a
single localized lesion in each affected
vessel and preserved LV function fare
best with PCI
Post Op angina , MI and
mortality
After 5 years: 25%
10 years : 50 %
15 or more years. : 85%
 PCI vs CABG in
Diabetics
In the BARI Registry, in which patients were
treated according to the preference of the
individual physician, and in two large data
base studies, poorer outcomes were noted
for both CABG and PTCA in diabetics versus
nondiabetics but, among diabetics, no
survival difference was noted between PTCA
and CABG
The comparison with DES vs CABG is not
available
Arterial Revascularization
Therapies Study (ARTS).
Estimates of survival free
of myocardial infarction,
cerebrovascular events,
or repeated
revascularization
 Other factors
Patients with LV dysfunction and evidence of
hibernating myocardium have a high mortality
rate during medical therapy and appear to
have a better outcome with revascularization
Perioperative morbidity after CABG has
remained, on average, two times higher in
women compared with men.
However, when adjusted for the greater risk
profile of women referred for CABG, short-
term mortality rates as well as long-term
outcomes are similar to those for men in
most, but not all, studies.
TR AN SMYO CARDI AL LASER
REV ASCU LARI ZATIO N.

Has been reported to improve

symptoms in patients with refractory
angina; however, the mechanism and
magnitude of benefit remain uncertain
There were observations demonstrating
closure of the channels within hours or
days (Placebo effect?)
The widespread use of TMLR as a
stand-alone method cannot be justified.
 Syndrome X
The syndrome of angina or angina-like chest
pain with a normal coronary arteriogram.
Some of them have increase lactate with
exercise but others don’t.
The incidence of coronary calcification is
higher.
20 percent of patients with chest pain and
normal coronary arteriograms have positive
exercise tests
 Endothelial dysfn.
Abnormally decreased capacity to reduce
coronary resistance and increase coronary
flow in response to stimuli such as exercise,
adenosine, dipyridamole, and atrial pacing.
These patients also have an exaggerated
response of small coronary vessels to
vasoconstrictor stimuli and an impaired
response to intracoronary papaverine.
Higher levels of circulating intercellular
adhesion molecule-1, vasoconstrictor
endothelin-1 and hsCRP
CMR demonstrated that subendocardial
perfusion abnormalities, in particular,
may be associated with syndrome X.
Decreased threshold for pain
perception—the so-called sensitive
heart syndrome.
 Management
Consider medical treatment in those with
persistent symptoms or positive stress tests.
Beta blockers and ACE inhibitors helpful
based on the pathophysiology but others like
nitrates, CCB, alpha blockers don’t help
Antidepressants and estrogen supplements
have been shown to work.
 Sile nt Myo cardial
Ischemia
Type I: Never have symptoms
Type II: Silent ischemia with previous MI
Type III: Silent ischemic episodes with
symptomatic episodes. Typically one third of
ischemia in chronic stable angina is silent.
Episodes of myocardial ischemia, regardless of
whether they are symptomatic or
asymptomatic, are of prognostic importance
in patients with CAD
LV aneurysm
 LV aneurysm
Almost 50 percent of patients with moderate
or large aneurysms have symptoms of heart
failure, with or without associated angina,
approximately 33 percent have severe angina
alone, and approximately 15 percent have
symptomatic ventricular arrhythmias that may
be intractable and life threatening. Mural
thrombi are found in almost half of patients
Aneurysmectomy for HF particularly with
angina.
Non atheromatous CAD
Prinzmetal angina
Anomalous origin of a coronary artery
CONNECTIVE TISSUE DISORDERS.
Marfan syndrome (causing aortic and coronary artery
dissection), Hurler syndrome (causing coronary
obstruction), homocystinuria (causing coronary artery
thrombosis), Ehlers-Danlos syndrome (causing
coronary artery dissection), and pseudoxanthoma
elasticum (causing accelerated CAD). Kawasaki
disease, the mucocutaneous lymph node syndrome),
SPONTANEOUS CORONARY DISSECTION.
CORONARY VASCULITIS.
TAKAYASU ARTERITIS.
POSTMEDIASTINAL IRRADIATION.
Infective endocarditis
<<<<<<THE END>>>>>>>