Intervention
Imaging guidance of interventional procedures
X-ray angiography is widely used to guide interventions, such as balloon angioplasty, atherectomy, laser treatment, stent placement, and other procedures. Current practice indicates the use of x-ray angiography in patients with potentially treatable lesions to confirm the findings and to perform interventions. Both tasks may be accomplished in a single procedure.
Cardiac catheterization is recommended for patients with mild angina (class I or II) plus an EF of less than 45%, including patients with noninvasive test results indicating a high risk, those with an uncertain diagnosis after noninvasive testing, patients with serious ventricular arrhythmias, and those who survive an episode of sudden death. The only indication with submaximal support is mild angina with reduced EF; this is a class IIa recommendation. The classification of indications by the American College of Cardiology indicates the weight of evidence in support of the recommendation. Mild angina with no reduction in EF might be managed with medication as a therapeutic trial.
As an experiment, MRI, CT, or echocardiography may be used to guide interventional procedures. MRI does not involve ionizing radiation; therefore, imaging may be active throughout the procedure. However, special guidewires and other equipment compatible with the magnet and the rapidly changing magnetic field must be used, and staff must be trained to ensure that no magnetic objects are brought near the magnet.
CT uses ionizing radiation and is slower than x-ray angiography, but it provides 3D information that may facilitate localization, especially for newer interventions such as the intramyocardial injection of angiogenic growth factors or stem cells. 3D ultrasonography similarly facilitates accurate injections, with convenience of portability and without a need for lead shielding from x-rays.
Prevention, treatment, repair, and new therapies
Prevention aims to slow or reverse the process that causes disease—for example, by lowering serum LDL-C levels (with statins); by increasing HDL-C levels (with exercise and niacin); by lowering lipoprotein(a) with niacin, fibrates, or other medication; and by counteracting the oxidation of LDL-C that accelerates wall uptake of the lipid (with vitamin C and selenium). Vigorous exercise every other day promotes overall health and the development of new vessels.
High levels of homocysteine are associated with the rapid development of disease. High homocysteine levels are as important as high cholesterol levels, and they can be treated by simply administering supplemental doses of folate and B-vitamins, adjusted to effect, but such treatment has not been shown to reduce the associated risk.
Growth factors, such as basic fibroblast growth factor 1 (bFGF1), basic fibroblast growth factor 2 (bFGF2), and vascular endothelial growth factor (VEGF) may stimulate the development of new vessels. These factors are administered experimentally either directly or by means of DNA-based therapies.5,39,40,41,42,43
Medical treatments aim to improve the blood supply as needed by dilating the vessels, typically with nitrates, and/or by decreasing the demand, typically with beta-blockers. Other medical treatments include thrombin inhibitors, IIb/IIIa inhibitors, and high-dose statins.
Repair aims to crack or crush a lesion (with angioplasty), remove a portion of the obstruction (with atherectomy or laser treatment), remove clot (with thrombectomy, passage of a wire, or thrombolysis), hold the vessel open at an increased diameter (with stent placement), apply local medication (with drug-eluting stent placement), provide new pathways (with bypass surgery), and/or stimulate the growth of new vessels (with therapeutic angiogenesis).
New site-specific drug-eluting stents chemically inhibit the reactive endothelial growth that causes early restenosis after angioplasty. The failure of vein grafts after mechanical intervention continues to pose a challenge. New devices (eg, Front Runner and Safe-Cross devices) have been developed to improve the ability to open totally occluded vessels, even chronic occlusions. One area of investigation is the protection of the distal vessel from debris during the treatment of acute MI or degenerating vein grafts. A current trend is to use PCI and complete revascularization, even in high-risk elderly patients.44
The typical clinical approach to CAD is an abnormal stress test followed by cardiac catheterization. If the catheterization identifies significant lesions (corresponding to inducible ischemia or to an acute coronary syndrome, or deemed significant by appearance or flow wire), then revascularization is planned either as part of the same catheterization or as a separate intervention. Intervention by catheterization is called percutaneous intervention (PCI) and by surgery is called coronary artery bypass grafting (CABG). If the patient was unstable from an acute threatened or actual myocardial infarction, the initial procedure by percutaneous intervention focuses on the culprit lesion.
Prior to the invention of drug eluting stents (DES), PCI was performed as plain-old balloon angioplasty (POBA), which might be supplemented by a bare metal stent (BMS), originally used to treat biliary stenoses. POBA was plagued by a high frequency of restenosis within months. BMS improved that for large diameter vessels in nondiabetics. Patients with 3-vessel CAD or left main disease or diabetes did better with CABG. The benefit of surgery over medical treatment was best demonstrated for severe CAD with reduced ejection fraction (EF) and for diabetics. POBA was only demonstrated to reduce symptoms. However, that data predates DES. Diabetics do well with DES, and now PCI with DES is performed not only on isolated one-vessel CAD but also on 3-vessel CAD and left main disease.
DES had a rocky initial experience that caused controversy, but now it is generally preferred treatment, particularly in high-risk lesions, small-caliber vessels, and patients with diabetes. DES prevents endothelial growth that may occlude a bare metal stent (BMS), but that also means that there is continued exposure of blood to metal and collagen, resulting in thromboemboli. That risk is offset by administering Plavix (clopidogrel) as well as aspirin, even in patients who are taking warfarin. Clopidogrel added to aspirin clearly lowers the risk of thrombosis and thromboembolus from a stent; clopidogrel alone has not been studied in any large trials.
Patients allergic to clopidogrel (1-2% of patients may develop a severe rash, itching, hives, or angioedema) may take Ticlid (ticlopidine), but ticlopidine may also cause an allergic reaction and may be markedly less effective; therefore, many patients may undergo clopidogrel desensitization concurrently so as to be able to resume taking clopidogrel. With BMS, clopidogrel is essential for the first 1-2 months. With DES, risk is high for the first 6 months, and there is a risk of sudden thrombosis for 1-2 years after clopidogrel.
Surgery is deferred for 2-3 months with BMS and for 6-12 months with DES. After DES, if there are no contraindications, clopidogrel plus aspirin is often continued indefinitely. Experimental new stents are under development that may allow a protective lining to grow over a stent without risk of obstruction of blood flow from endothelial overgrowth, which may eliminate the long-term need for antiplatelet therapy with concomitant risk of a serious bleeding event.45,46,47,48,49,50,51
Medicolegal Pitfalls
- Failure to perform timely screening and/or catheterization in a patient referred for evaluation may create liability for the physician if the patient subsequently has a cardiovascular event that might have been prevented if the disease had been discovered earlier.
- Other pitfalls are listed below:
- Performing a routine stress test in a patient with symptoms from severe aortic stenosis
- Giving nitrates to a patient in the upright position who is taking Viagra or Cialis without also giving intravenous saline, performing careful BP monitoring, and advising the patient about a possible life-threatening hypotension
- Failure to obtain promptly an EKG or otherwise properly evaluate and treat a patient with an angina-equivalent condition or silent MI who presents with painless shortness of breath, fatigue, or other painless angina-equivalent symptoms
- Failure to promptly relieve ischemia by applying the relevant treatment options
- Misinterpreting intimal dissection as stenosis or thrombosis, which may result in the avoidable death of a patient
- Failure to identify spasm and to promptly initiate appropriate treatment
- Failure to treat stenosis of the left main coronary artery or its equivalent with appropriate urgency and use of precautionary measures
- Complications from performing an intervention in a nonculprit lesions in an acute setting
More on Coronary Artery Disease |
| Overview: Coronary Artery Disease |
| Imaging: Coronary Artery Disease |
 Follow-up: Coronary Artery Disease |
| Multimedia: Coronary Artery Disease |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics
Coronary Artery Calcification - CT
Coronary Artery Atherosclerosis
Primary and Secondary Prevention of Coronary Artery Disease
Risk Factors for Coronary Artery Disease
Comparison of Revascularization Procedures in Coronary Artery Disease
Clinical guidelines
The Primary and Secondary Prevention of Coronary Artery Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Drug-Eluting Stents for the Treatment of Coronary Artery Disease
Clinical studies
Influenza Vaccination in Prevention From Acute Coronary Events in Coronary Artery Disease - FLUCAD Study
Exercise Training, Insulin Resistance and Coronary Artery Disease
Keywords
coronary artery disease, CAD, heart disease, coronary angiography, coronary angioscopy, coronary artery imaging, magnetic resonance angiography, MRA, stress test, perfusion imaging, collateral-sensitive imaging, heart attack, myocardial infarction, MI, acute myocardial infarction, AMI, angina, UA, unstable angina, stent, DES, drug-eluting stent
