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Coronary Arteries,[object Object],The Basics and Beyond,[object Object]
Function of coronary arteries: delivery of oxygenated blood to the heart muscle (myocardium),[object Object],The VERY Basics,[object Object],How-to-draw-cartoons-online.com,[object Object]
Left coronary artery:  arises from the left coronary sinus/cusp of the Aortic valve,[object Object],Left main artery branches into:,[object Object],LAD- Left Anterior Descending ,[object Object],CX- Circumflex,[object Object],Right coronary artery:  arises from the right coronary sinus/cusp of the Aortic valve,[object Object],Main Branches,[object Object]
Coronary arteries lie on top of the myocardium (epicardial) and follow the Atrioventricular (AV) groove and the Interventricular (IV) groove,[object Object],CX courses along AV groove,[object Object],LAD and distal RCA follow IV groove,[object Object],Basics, cont,[object Object]
Cvphysiology.com,[object Object]
LAD:  diagonals and septals,[object Object],CX:  obtuse marginals, occasionally Posterior descending artery (PDA),[object Object],RCA:  acute marginals, Posterior lateral artery (PLA), and PDA,[object Object],Ramusintermedius:  arises between LAD and CX in 5%-10% of population,[object Object],Major Branches,[object Object]
A person can be “right dominant”, “left dominant”, or “co-dominant”.,[object Object],This depends on which artery (or arteries) give rise to the PDA and PLA, which run along the posterior side of the heart.,[object Object],Coronary Dominance,[object Object]
Right Dominant,[object Object],The PDA branch arises from the RCA (60%-70% of population),[object Object]
Left Dominant,[object Object],The PDA arises from the LCA (10%-15% of population),[object Object]
RCA gives rise to the PDA and then ends, while the CX supplies the PLA branches,[object Object],CX may also supply a left PDA that runs parallel to the right PDA,[object Object],Co-Dominant,[object Object]
As with all structures in the human body, WEIRD stuff can happen!  A few examples:,[object Object],CX originates with RCA from right sinus,[object Object],LM from right sinus,[object Object],RCA from left sinus,[object Object],Separate originations (ostia) for all three,[object Object],All three arteries from one ostia,[object Object],Variations and Anomalies,[object Object]
Coronary aneurysms,[object Object],Fistulas- abnormal communication with venous system,[object Object],Anomalous 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),[object Object],Anomalies,[object Object]
Adventitia- outermost, connective tissue covering the vessel,[object Object],Media- smooth muscle cells,[object Object],Spasm- contraction of cells causing disturbance of blood flow (caused by numerous factors:  caffeine or stimulant induced, catheter induced),[object Object],Intima- innermost, single layer of cells,[object Object],Anatomy of an Artery,[object Object]
Ncbi.nlm.nih.gov,[object Object]
Coronary Arteries
LAD supplies:  most of septum, anterior/lateral/apical LV, anterolateral pap muscle,[object Object],CX supplies:  LA, posterior/lateral LV, anterolateral pap muscle, SA node (45%), AV node (10%), septum, His bundle, posterior pap muscle, inferoposterior LV,[object Object],RCA supplies:  SA node (55%), RA, AV node (90%), septum, His bundle, posterior pap muscle, inferoposterior LV,[object Object],Myocardial Blood Supply,[object Object]
Myocardial Blood Supply,[object Object],Med.yale.edu,[object Object]
Coronary Arteries perfuse in diastole (this is part of the theory behind the IABP),[object Object],Coronary sinus collects used blood from the mycardium to send to lungs for re-oxygenation,[object Object],Coronary bridging = compression of a coronary artery by the myocardium during systole,[object Object],Usually benign, but can occasionally result in MI or even death (most common with LAD),[object Object],Hemodynamics,[object Object]
Several medications are injected to elicit vasodilation in the arteries during catheterization, such as diltiazem, verapamil, adenosine, nitroglycerine, and nipride,[object Object],IIbIIIa Inhibitors (abciximab, eptifibitide) are also directly injected in coronary arteries with apparent thrombus,[object Object],Pharmacology,[object Object]
CAD and Atherosclerosis:  What does this mean, exactly?,[object Object],Build-up of fatty substances, cholesterol, cellular waste products, and calcium within the intima of an artery,[object Object],With or without symptoms,[object Object],Coronary Artery Disease,[object Object]
Pathophysiology of CAD,[object Object]
Rupture of fibrous cap,[object Object],Platelets rush in to fix the vessel,[object Object],Clot forms,[object Object],Blood flow obstructed,[object Object],Damage/death of myocardium,[object Object],Pathophysiology of Acute MI,[object Object]
Many tests and screening tools are available to help detect CAD,[object Object],Can be invasive or non-invasive,[object Object],Can be performed in MD’s office or hospital, depending on type of test,[object Object],Diagnostic Testing Methods,[object Object]
Treadmill- assesses coronary blood flow by ECG, blood pressure, and signs/symptoms during exercise,[object Object],Stress Tests,[object Object]
Coronary Arteries
Stress Echocardiogram-compares LV wall motion at rest and under stress,[object Object],Used for low-moderate risk patients and younger patients where there may be structural/valvular/congenital causes of symptoms,[object Object],Stress Tests,[object Object],Johnson.com,[object Object]
Perfusion scan- compares blood flow at rest and under stress by imaging the myocardium after a radioactive tracer is injected,[object Object],Stress Tests,[object Object],Bocacardiology.com,[object Object]
Echocardiogram- assesses structural, valvular, and congenital causes of heart disease,[object Object],Diagnostic Testing,[object Object],Brighamandwomens.org,[object Object]
Cardiac MRI- useful for diagnosis of structural disease (cardiomyopathy, masses) with or without contrast,[object Object],Gold standard for congenital heart disease,[object Object],Diagnostic Testing,[object Object]
Cardiac Computed Tomography(CT)- evaluates coronary arteries as well as LV function, anatomy, and calcification (calcium score),[object Object],Diagnostic Testing,[object Object],Imagingeconomics.com,[object Object]
Cardiac CT Images,[object Object],Csmc.edu,[object Object],64ctscan.com,[object Object]
Coronary Angiography- used for positive and indeterminate stress tests, assessment of bypass grafts,[object Object],Also for patients with known history of CAD,[object Object],Gold standard for coronary evaluation,[object Object],Diagnostic Testing,[object Object],Circulation.or.kr,[object Object]
IVUS- small ultrasound catheter is inserted in the coronary artery to image the vessel and assess plaque,[object Object],Can differentiate between fibrous and calcified plaque,[object Object],Virtual histology,[object Object],Diagnostic TestingIntravascular Ultrasound,[object Object],Ptca.org,[object Object]
Technically: the ratio of blood flow in a stenotic artery to normal flow,[object Object],Essentially: a stress test on a specific artery,[object Object],Flow is measured by a special guidewire, using flow measurements beyond the lesion and comparing them with flow before the lesion,[object Object],IV infusion of Adenosine is used to increase HR ,[object Object],Ratio is calculated from a 2-3 minute period,[object Object],Normal value = 1.0,[object Object],Abnormal value = <0.75,[object Object],Diagnostic TestingFractional Flow Reserve (FFR),[object Object]
Treatment of CAD,[object Object],Medical treatment- managing the patient’s medications to help alleviate symptoms,[object Object],Percutaneous Coronary Intervention (PCI)- used in various situations, from single lesions to complex, high-risk multi vessel disease,[object Object]
Nhlbi.nih.gov,[object Object]
Treatment of CAD,[object Object],Coronary Artery Bypass Grafting- most often used for severe multi vessel disease and diabetic patients,[object Object],Beaumonthospitals.com,[object Object]
We’ve come a long way from the first accidental coronary angiogram in 1958…,[object Object],Diagnosis and treatments continue to evolve,[object Object],Coronary Arteries Summary,[object Object]
Peripheral Arterial Disease (PAD),[object Object],Same arterial anatomy and disease process, but most patients (with exception of CVA) tend to wait much longer to seek treatment,[object Object],May mimic arthritis, neuropathy,[object Object],Symptoms attributed to “old age”,[object Object],What about Peripheral Vascular Disease?,[object Object]
Claudication- leg pain with walking that resolves at rest,[object Object],Decreased temperature of extremity,[object Object],Non-healing wounds,[object Object],Symptoms of LE PAD,[object Object]
Sudden numbness or weakness, especially on one side,[object Object],Sudden confusion, trouble speaking,[object Object],Sudden trouble seeingin one or both eyes,[object Object],Sudden dizziness, loss of balance and coordination,[object Object],Sudden severe headache,[object Object],Symptoms of CVA,[object Object]
Ultrasound/Doppler studies,[object Object],MRI/MRA,[object Object],CT/CTA,[object Object],Angiography,[object Object],Diagnostic Testing for PAD,[object Object]
Medications,[object Object],PercutaneousTransluminal Angioplasty (PTA) with or without stent placement,[object Object],Atherectomy,[object Object],Bypass surgery,[object Object],Treatment of PAD,[object Object]
Interventions done for high-risk, asymptomatic or symptomatic patients (depends on clinical study enrollment),[object Object],All patients must be enrolled in a research study to receive a stent,[object Object],Typical 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 location,[object Object],Carotids,[object Object]
Cleveland Clinic Heart and Vascular Institute,[object Object]
Code Stroke,[object Object],An Interdisciplinary effort to get treatment started for stroke victims ASAP,[object Object],Emcompasses:  ED assessment, activation of Code Stroke protocol, Neurology consults, CT scans, Interventional Cardiology consults, thrombolytic treatment if indicated, invasive intervention if indicated,[object Object]
Renals,[object Object],Interventions performed for poorly controlled hypertension or poor renal function,[object Object],Rivascularinstitute.com,[object Object]
Interventions performed for claudication, critical limb ischemia (non healing wounds), and limb salvage,[object Object],Lower Extremity,[object Object]
Radiologyrsnajnls.org,[object Object]
PAD,[object Object],Basically, if we can get a catheter to an artery, we can take a picture and potentially intervene!,[object Object],Mesenterics,[object Object],Subclavians,[object Object],ETC…,[object Object]
Fast growing segment of cardiac cath lab procedures,[object Object],Percutaneous treatments are constantly being developed,[object Object],PAD Summary,[object Object]
Cvphysiology.com,[object Object],Heartsite.com,[object Object],NEJM, Vol. 360 No.3,[object Object],Ncbi.nlm.nih.gov,[object Object],Encyclopedia Brittanica,[object Object],Med.yale.edu,[object Object],Johnson.com,[object Object],Bocacardiology.com,[object Object],Brighamandwomens.org,[object Object],Nature Publishing Group,[object Object],Emedicine.medscape.com,[object Object],Sources,[object Object]
64ctscan.com,[object Object],Csmc.edu,[object Object],Circulation.or.kr,[object Object],Ptca.org,[object Object],Beaumonthospitals.com,[object Object],Nhlbi.nih.gov,[object Object],Cleveland Clinic Heart and Vascular Institute,[object Object],Rivascularinstitute.com,[object Object],Radiologyrsnajnls.org,[object Object],Imagingeconomics.com,[object Object],How-to-draw-cartoons-online.com,[object Object],Sources,[object Object]

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Editor's Notes

  1. 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).
  2. Those in the cath lab know this from ACC database…
  3. The one that seems most common is the first example…
  4. 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)
  5. Knowledge of myocardial blood supply comes in handy when interpreting an ECG…
  6. 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…
  7. An IABP inflates during diastole, which will push more blood down the coronaries when the LV has been damaged…
  8. 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.
  9. How do we find as many of these people as possible before the MI happens?
  10. So, what are the options for a patient with significant CAD?
  11. 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…