Lecture 5 Flashcards
(29 cards)
revascularization procedures: goals
- restore myocardial blood flow
- improve prognosis
- —mortality
- —morbidity
revascularization procedures: CABS
coronary artery bypass surgery
-more invasive
revascularization procedures: PCI
- “by the way of skin”
- percutaneous transluminal coronary angioplasy (PCTA)
- silent therapy
- PTCA with stent
How common in 2008?
CABS: 240,000 cases
PCI: 817,000 cases
Pathophysiology
ARTHERSCLEROSIS
FACTORS CONSIDERED FOR REVASCULARIZATION
- significant lesions
- —> 50% senosis
- location of lesion
- stability of plaque
- prognosis
- quality of life
CABS
- using graft bypass area of occlusion
- —saphenous vein
Indication of CABS
- re-stenosis after PCI
- multi-vessel disease
- offucult lesions
- disease not amendable to PCI
CABS may involve
sterotomy
-avoided by recent technological advances
heart-lung bypass
-heart stops
Advances in CABS
- mini-surgery
- robotic technology
- surgery on beating heart
- —no heart lung bypass
Who Should Have CABS
primary for patients
- post PCI with stenosis
- multi-vessel disease not amenable PCI
- difficult lesions
- –bifurcations
- –distal
other cases
-PCI
CABS OUTCOMES
INCREASED: senovial rate, F.C., left ventricular function, HR Max, RPP, quality of life
REDUCED: angina, ischemia, ST-segment depression
[CABS] Outcomes depend on
- severity and location of lesion
- age
- comorbidities
[CABS] Re-occulsion rate
10% at 1 year
20% at 5 year
40% at 11 year
PTCA
widening narrowed or obstructed vessels
techniques
- balloon dilations
- –most common
- rotational atherectomy
- –central bulky lesions
- directional atherectomy with laser
- –large lesions
- –high risk for damage to vessel
PTCA OUTCOMES
RELATIVELY SAFE
-patient often awake
RELIEVES
-angina
IMPROVES
- quality of life
- functional capacity
RESTENOSIS COMMON
- within 6 months
- 25% of patients
MEDICAL ATTENTION POST PCA IMPORANT
-behavioral modification
-
—physical activity smoking cessation, diet, weight loss, etc.
Complications of PTCA
- acute vessel closure
- chromic restenosis
- thrombotic distal embolism
- myocardial infarction
- arrythymia
- coronary artery dissection
- bleeding
Stent Therapy
A tube keeping arteries open
- steel framework
- eventually covered endothelium
- drug-eluting
- —reduce
- ——acute complications
- ——restenosis
Often used with PTCA
Drug-Eluting Silent
Coated with slowly released medication
- to prevent the growth of scar tissue in artery lining
- –metal stents may cause tissue to grow over stent
- ——leading to REBLOCKAGE
- helps artery remain smooth and open
Stent Therapy Outcomes
RELIEVES angina IMPROVES functional capacity and quality of life RESTONSIS -bare metal ---24-40% -drug eluting ---40% OUTCOMES depend on comorbidities MEDICAL ATTENTION POST PTCA IMPORTANT -medications -behavior modification ----physical activity smoking cessation, diet, weight loss, etc.
GXT Considerations: CABs
Hospital Stay post-CABs
-2-5 days
Submaximal
-predischarge
Symptom-limited
-3-4 weeks post-CABs
Wound Healing
- chest
- leg
GXT Considerations: PTCA and Stents
Hospital stay post-PTCA
- 1-2 days
- often outpatient
GXT
-not important immediately
Symptoms
-may indicated re-stenosis
Cardiac Rehabilitation-Impatient
Components -ambulation -range of motion exercises -education for PCIs minimal -some might be done at home
Cardiac Rehabilitation-Outpatient
- should start as early as possible
- multifactorial
- —education for patients and spouses
- more room for improvement for CABs then PCI
- exercise even without PCI
- –start with lighter intensities
- –increase intensity and volume progressively
Benefits of Exercise
Improvements -cardiac function -functional capacity -less angina during exercise -less re-stenosis post PCI Less Mortality -8-17% reduction in mortality risk ---for every 1 MET improvement -faster return to work -less re-admission -psychological benefits ---greater self-efficacy ---less depression and stress
