Coronary Angiography and Profiles in Coronary Artery Disease

Speaker: Speaker: 蔣 俊 彥蔣 俊 彥Supervisor:Supervisor: 李貽恆醫師李貽恆醫師

Grossman’s cardiac catheterization, Grossman’s cardiac catheterization, angiography, and interventionangiography, and intervention

Current Indications

A. Further evaluation of coronary atherosclerosisA. Further evaluation of coronary atherosclerosis Stable angina pectoris refractory to medical therapyStable angina pectoris refractory to medical therapy Asymptomatic patients with noninvasive evidence of Asymptomatic patients with noninvasive evidence of

myocardial ischemia myocardial ischemia Unstable angina or positive exercise test Unstable angina or positive exercise test

B. Primary angiography for AMI B. Primary angiography for AMI

C. Post-MI angina , arrhythmias, congestive heart C. Post-MI angina , arrhythmias, congestive heart failure , or EF<40% failure , or EF<40%

D. Non-Q MI and ongoing IRA and suspected 3 D. Non-Q MI and ongoing IRA and suspected 3 vessels disease vessels disease E. Mechanical defect after an MI (such as VSD, E. Mechanical defect after an MI (such as VSD, papillary muscle rupture)papillary muscle rupture)F. Uncertain of coronary artery disease(troublesome F. Uncertain of coronary artery disease(troublesome chest pain syndrome, unexplained heart failure or chest pain syndrome, unexplained heart failure or

ventricular arrhythmias, survivors of out-of hospitventricular arrhythmias, survivors of out-of hospital cardiac arrest, suspected or proven varient anginal cardiac arrest, suspected or proven varient angina)a)

G. Patients with risk factor for coronary artery G. Patients with risk factor for coronary artery disease for major abdominal, thoracic , or disease for major abdominal, thoracic , or vascular surgery.vascular surgery.H. Congenital or valvular heart disease with age>45 H. Congenital or valvular heart disease with age>45 y/oy/oI. Preoperative diagnostic catheterization for I. Preoperative diagnostic catheterization for

significant coronary lesion significant coronary lesion J. Recurrent angina after coronary intervention or J. Recurrent angina after coronary intervention or

after bypass surgery after bypass surgery

General Issues

4-6 hours of bed rest after a percutaneous femoral 4-6 hours of bed rest after a percutaneous femoral procedure procedure

NPO 6-8 hours before catheterization except mediNPO 6-8 hours before catheterization except medication or liquid cation or liquid

Oral sedation before catheterizationOral sedation before catheterization Baseline EKG Baseline EKG

The Femoral Apprpach

Insertion and Flushing of the Coronary Catheter

Damping and Ventricularization of the Pressure Waveform

Severely restricting or occluding ostial inflow

Damping and Ventricularization of the Pressure waveformDamping and Ventricularization of the Pressure waveform A fall in overall catheter tip pressure (damping) or a fall in A fall in overall catheter tip pressure (damping) or a fall in

diastolic pressure only (ventricularization) during catheter diastolic pressure only (ventricularization) during catheter engagement in a coronary ostium indicates restriction of coengagement in a coronary ostium indicates restriction of coronary inflow.ronary inflow.

The catheter tip may have been inserted into a proximal coThe catheter tip may have been inserted into a proximal coronary stenosis and the catheter ronary stenosis and the catheter should be withdrawnshould be withdrawn into t into the aortic root immediately .he aortic root immediately .

A nonselective injection into sinus of Valsalva in an approA nonselective injection into sinus of Valsalva in an appropriate view to confirm the presence of an ostial stenosis.priate view to confirm the presence of an ostial stenosis.

Vigorous injectionVigorous injection despite a damped or ventricularized pre despite a damped or ventricularized pressure waveform ssure waveform should be avoidedshould be avoided , because it prediposes t , because it prediposes to o ventricular fibrillationventricular fibrillation or or dissection of the proximal corodissection of the proximal coronary arterynary artery with major ischemic sequale. with major ischemic sequale.

Cannulation of Coronary Ostium with a Judkins catheter

Cannulation of the left Coronary Ostium with an Amplatz catheter

Saphenous vein graft angiography

Internal mammary angiography

Gastroepiploic graft angiography

The Brachial Cutdown ApproachSelective catheterization of the left coronary artery by Sones catheter

Selective catheterization of the right coronary artery by Sones catheter

Adverse Effects of Coronary Angiography

High osmolar contrast agentHigh osmolar contrast agent may have potential deleteriou may have potential deleterious effects that include s effects that include (a)(a) transient (10-20 seconds ) transient (10-20 seconds ) hemodyhemodynamic depressionnamic depression marked by arterial hypotension and marked by arterial hypotension and elevelevation of the left ventricular end-diastolic pressureation of the left ventricular end-diastolic pressure (b)(b) ECG ECG effectseffects with T-wave inversion or peaking in the inferior lea with T-wave inversion or peaking in the inferior leads , sinus slowing or arrest , and prolongation of the PR, Qds , sinus slowing or arrest , and prolongation of the PR, QRS, and QT intervalsRS, and QT intervals

(c)(c) significant arrhythmiasignificant arrhythmia (asystole or ventricular tachycard (asystole or ventricular tachycardia /fibrillation)ia /fibrillation)

(d)(d) myocardial ischemiamyocardial ischemia due to interruption of oxygen deli due to interruption of oxygen delivery or coronary steal very or coronary steal

(e)(e) allergic reactionallergic reaction (f)(f) cumulative renal toxicitycumulative renal toxicity

Most episodes of Most episodes of bradycardiabradycardia or or asystoleasystole are resolved pro are resolved promptly by a mptly by a forceful coughforceful cough which elevates central aortic pre which elevates central aortic pressure and helps wash residual contrast material out of the ssure and helps wash residual contrast material out of the myocardial capillary bed. myocardial capillary bed.

True life-threatening bradycardia is very uncommon and cTrue life-threatening bradycardia is very uncommon and can be managed successfully by an be managed successfully by coughcough and and temporary pacetemporary pacemaker.maker.

Prophylatic drugs , a defibrillator , and airway managemenProphylatic drugs , a defibrillator , and airway management equipment are kept at the ready into play within seconds t equipment are kept at the ready into play within seconds

The most common adverse effects is the provocation of The most common adverse effects is the provocation of mmyocardial ischemiayocardial ischemia , particularly in patients with , particularly in patients with unstable aunstable angina.ngina. The best course of action is The best course of action is to remove the catheter fto remove the catheter from the coronary ostium and temporarily suspend injectiorom the coronary ostium and temporarily suspend injections until angina resolvesns until angina resolves. . NTG (200ug -1000 ug) bolus if chNTG (200ug -1000 ug) bolus if chest pain is over 30 secondsest pain is over 30 seconds. .

In patients with inappropriate tachycardia in the setting of In patients with inappropriate tachycardia in the setting of unstable angina and adequate LV performance. Iv unstable angina and adequate LV performance. Iv propranpropranolololol (1mg every minutes to total dose of 0.1-0.15 mg/kg) o (1mg every minutes to total dose of 0.1-0.15 mg/kg) or r esmololesmolol. .

Refractory myocardial ischemiaRefractory myocardial ischemia to medicine prompt place to medicine prompt placement of an ment of an intraaortic counterpulsation balloonintraaortic counterpulsation balloon .It may req .It may require immediate treatment with additional vasodilators, balluire immediate treatment with additional vasodilators, balloon angioplasty, thrombolysis, or oon angioplasty, thrombolysis, or emergent bypass surgeryemergent bypass surgery..

Severe allergic reactionsSevere allergic reactions are uncommon and can prevented are uncommon and can prevented by 18-24 hours of by 18-24 hours of premedicationpremedication (prednisolone 20-40 mg , (prednisolone 20-40 mg , cimetidine 300mg q6h) or use nonionic contrast agent in pcimetidine 300mg q6h) or use nonionic contrast agent in pateints with allergy history. Bosmine (1:10000) was availaateints with allergy history. Bosmine (1:10000) was available in emergency.ble in emergency.

Renal insufficiencyRenal insufficiency may develop after coronary angiograp may develop after coronary angiography , particularly in patients who are hy , particularly in patients who are hypovolemic hypovolemic , who rec, who received eived large volumes of contrastlarge volumes of contrast material ( material (more than 3ml/kmore than 3ml/kgg) or have had ) or have had renal insuffiencyrenal insuffiency , , diabetesdiabetes or or multiple myelmultiple myelomaoma. Adequate hydration before and after the procedure.. Adequate hydration before and after the procedure.

Injection Technique

Injection Technique

Too timidToo timid an injection allows intermittent entry of an injection allows intermittent entry of nonopaque blood into the coronary artery and prevents nonopaque blood into the coronary artery and prevents visualization of the coronary ostium and proximal visualization of the coronary ostium and proximal coronary branches. coronary branches.

Too vigorousToo vigorous an injection can cause an injection can cause coronary dissectioncoronary dissection or or excessive myocardial blushingexcessive myocardial blushing and too prolonged an and too prolonged an injection may contribute to increased myocardial injection may contribute to increased myocardial depression or bradycardia.depression or bradycardia.

The injection amount is average The injection amount is average 7ml at 2.1ml/sec7ml at 2.1ml/sec in the in the leftleft and and 4.8 ml at 1.7ml/sec4.8 ml at 1.7ml/sec in the in the right right coronary artery. coronary artery.

In patients with In patients with left ventricular hypertrophyleft ventricular hypertrophy (e.g., aortic (e.g., aortic stenosis, hypertrophy myopathy) , much larger volumes stenosis, hypertrophy myopathy) , much larger volumes and higher rates of injection may be required. and higher rates of injection may be required.

Anatomy, AngiographicViews, and Quantitation of Stenosis

Bypass Angioplasty Revascularization Investigation(BARI)

Right Anterior Oblique Projections

RAO-caudalRAO-caudal projection (0 projection (0 °°-10 -10 ° RAO and 15° RAO and 15 °-20°-20 °cauda°caudal) and it provides an excellent view of the l) and it provides an excellent view of the left main bifurcaleft main bifurcationtion , , the proximal LAD arterythe proximal LAD artery, and the , and the proximal to middle proximal to middle circumflex artery. circumflex artery.

RAO-cranialRAO-cranial projection (0 projection (0 °-10°-10 °RAO and 25°RAO and 25 °-40°-40 °° crania cranial), which provides a superior view of l), which provides a superior view of middle and distal LAmiddle and distal LADD, with clear visualization of the origins of the , with clear visualization of the origins of the septal and dseptal and diagonal branchesiagonal branches . It is also good for examination of the . It is also good for examination of the disdistal right coronary arterytal right coronary artery or or distal circumflex. distal circumflex.

Left Anterior Oblique Projections

LAO-cranialLAO-cranial view(45 view(45 ° LAO and 30° LAO and 30 °cranial ) shows °cranial ) shows left left mainmain and and proximal LAD arteriesproximal LAD arteries . .

LAO-caudalLAO-caudal view (40 view (40 °- 60°- 60 °LAO and 10°LAO and 10 °-20°-20 °caudal)°caudal) shows left coronary artery upward from the left main in the shows left coronary artery upward from the left main in the appearance of a spider , and usually offers improved appearance of a spider , and usually offers improved visualization of the visualization of the left main , proximal LAD, and left main , proximal LAD, and proximal circumflexproximal circumflex arteries. It is particularly valuable in arteries. It is particularly valuable in patients whose heart has a horizontal lie. The spider view patients whose heart has a horizontal lie. The spider view (LAO-caudal ) can often be enhanced by filming during (LAO-caudal ) can often be enhanced by filming during maximal expiration. maximal expiration.

Posterioranterior and left lateral Projections

PA projection provides the best view of the PA projection provides the best view of the left main ostiuleft main ostium. m.

RAO-caudalRAO-caudal view provides a better look at the view provides a better look at the more distal more distal left main artery. left main artery.

The left lateral projection is particularly useful in examininThe left lateral projection is particularly useful in examining the g the proximal circumflex and the proximal and distal LAproximal circumflex and the proximal and distal LAD arteriesD arteries. It also provides the best look at the anastomosis . It also provides the best look at the anastomosis of of left internal mammary graft to the mid-distal LADleft internal mammary graft to the mid-distal LAD and a and an excellent look at the n excellent look at the midposition of right coronary arterymidposition of right coronary artery. .

Right Coronary Angiography

LAO 40 LAO 40 ° + cranial 10° + cranial 10 °° is to visualize the is to visualize the proximal right cproximal right coronary artery.oronary artery.

RAO 45 RAO 45 °-°-cranialcranial is to visualize the is to visualize the posterior descending aposterior descending and posterolateral branches. nd posterolateral branches.

Lateral view(AP+cranial 30 Lateral view(AP+cranial 30 °) is to visualize the middle ri°) is to visualize the middle right coronary artery. ght coronary artery.

Lesion Quantification

The ability of coronary angiography to quantify the degree The ability of coronary angiography to quantify the degree of stenosis at different points is by a “ of stenosis at different points is by a “ lumen-o-gramlumen-o-gram” , in ” , in which each stenosis can be evaluated only by comparison twhich each stenosis can be evaluated only by comparison to adjacent ‘reference’ segment that is presumed to be o adjacent ‘reference’ segment that is presumed to be free ofree of disease. f disease.

The normal caliber of the major coronary arteries: The normal caliber of the major coronary arteries: 4.5±0.5 4.5±0.5 mm for left main coronary arterymm for left main coronary artery, , 3.7±0.4mm for the LAD3.7±0.4mm for the LAD, , 3.4±0.5mm for a nondominant versus 4.2±0.6mm for a do3.4±0.5mm for a nondominant versus 4.2±0.6mm for a dominant circumflexminant circumflex, and 3.9±0.6mm for a dominant versus 2., and 3.9±0.6mm for a dominant versus 2.8±0.5mm for a nondominant right coronary artery. 8±0.5mm for a nondominant right coronary artery.

By comparing the diameter of a presumably disease-free seBy comparing the diameter of a presumably disease-free segment of coronary artery to the size of the diagnostic cathetgment of coronary artery to the size of the diagnostic catheter (6F=2mm) , the operator can identify vessels that fall beler (6F=2mm) , the operator can identify vessels that fall below these normal size ranges and may be diffusely disease. ow these normal size ranges and may be diffusely disease.

Animal data and human data show that Animal data and human data show that a stenosis that redua stenosis that reduces the lumen diameter by 50%ces the lumen diameter by 50% (hence reducing the cross-s (hence reducing the cross-sectional area by 75%) is “ ectional area by 75%) is “ hemodynamically significanthemodynamically significant ” i ” in that it reduces the normal three-to four –fold flow reserve n that it reduces the normal three-to four –fold flow reserve of a coronary bed. of a coronary bed.

Lesions that permit a flow increase of more than two-fold Lesions that permit a flow increase of more than two-fold or that have a ratio of distal pressure to aortic pressure greaor that have a ratio of distal pressure to aortic pressure greater than 0.75 in the setting of peak flow after adenosine injter than 0.75 in the setting of peak flow after adenosine injection are generally considered not to be hemodynamically ection are generally considered not to be hemodynamically significant and usually have a diameter stenosis less than 5significant and usually have a diameter stenosis less than 50% by quantitative angiography. 0% by quantitative angiography.

Percent stenosis then can be calculated as Percent stenosis then can be calculated as 100×100×[1-(stenosis [1-(stenosis diameter/reference diameter)]diameter/reference diameter)]

Features such asFeatures such as eccentricity eccentricity , , ulcerationulceration , and , and thrombusthrombus may be associated with unstable clinical patterns and may be associated with unstable clinical patterns and features such as calcification ,eccentrically , or thrombus features such as calcification ,eccentrically , or thrombus may influence the choice of catheter intervention. may influence the choice of catheter intervention.

The absence of lesions that narrow the coronary lumen by The absence of lesions that narrow the coronary lumen by more than 50% does not necessarily confer immunity from more than 50% does not necessarily confer immunity from subsequent coronary events and it is frequently a lesion subsequent coronary events and it is frequently a lesion that has a large lipid core and a thin fibrous cap that that has a large lipid core and a thin fibrous cap that predisposes to subsequent plaque rupture and the resulting predisposes to subsequent plaque rupture and the resulting coronary thrombosis. coronary thrombosis.

Coronary Collaterals

These occluded or severely stenotic vessels are seen frequeThese occluded or severely stenotic vessels are seen frequently to fill late in the injection by ntly to fill late in the injection by antegradeantegrade(so-call (so-call bridginbridgingg ) collaterals or ) collaterals or collaterals that originate from the same (incollaterals that originate from the same (intracoronary )tracoronary ) or or the adjacent (intercoronary) vesselthe adjacent (intercoronary) vessel

The angiographic presence of collateral flow to an area in tThe angiographic presence of collateral flow to an area in the distribution of an occluded coronary artery is one of the he distribution of an occluded coronary artery is one of the strongest evidences of ongoing myocardial viability and an strongest evidences of ongoing myocardial viability and an important factor in determining the best revascularization simportant factor in determining the best revascularization strategy. trategy.

Nonartherosclerotic Coronary Artery Disease

Coronary Vasospasm

A episode of spontaneous chest pain with ST elevation in the territory A episode of spontaneous chest pain with ST elevation in the territory supplied by the vasospastic artery. Absence of a significant coronary lsupplied by the vasospastic artery. Absence of a significant coronary lesion in such a patient . Coronary angiography is performed mainly to esion in such a patient . Coronary angiography is performed mainly to look at the extent of look at the extent of underlying atherosclerosisunderlying atherosclerosis. .

Provocational testProvocational test (ergonovine, methyl-ergonovine maleate(ergonovine, methyl-ergonovine maleate) Test is o) Test is only nly performed after baseline angiographic evaluationperformed after baseline angiographic evaluation. It . It should not be should not be performed in patients with severe hypertension or severe anatomic carperformed in patients with severe hypertension or severe anatomic cardiac pathology ( left ventricular dysfunction, left main , or multivessel diac pathology ( left ventricular dysfunction, left main , or multivessel disease , aortic stenosis)disease , aortic stenosis)

If provocative testing produces clinical symptoms , but If provocative testing produces clinical symptoms , but no ECG changno ECG changes or angiographic evidence of vasospasmes or angiographic evidence of vasospasm in either coronary artery , a in either coronary artery , an alternative diagnosis such as n alternative diagnosis such as esophageal dysfunctionesophageal dysfunction is suggested. is suggested.

Coronary artery spasm Coronary artery spasm may occur in two vesselsmay occur in two vessels. The prov. The provocative test should be considered positive only if focal spasocative test should be considered positive only if focal spasm (greater than 70% diameter stenosis) and is associated wm (greater than 70% diameter stenosis) and is associated with clinical symptoms and ECG changes. ith clinical symptoms and ECG changes.

True coronary spasm must also be distinguished from spasTrue coronary spasm must also be distinguished from spasm induced by mechanical interventions such as m induced by mechanical interventions such as rotational arotational atherectomytherectomy or or catheter tip spasmcatheter tip spasm. . Catheter tip spasmCatheter tip spasm is mo is most common in right coronary artery, is not associated with cst common in right coronary artery, is not associated with clinical symptoms or ECG change. linical symptoms or ECG change.

Spasm should be distinguished from a “Spasm should be distinguished from a “ pleating pleating” artifact ” artifact may occur when a curved artery is straightened out by a stimay occur when a curved artery is straightened out by a stiff guidewire. ff guidewire. Pleating is refractory to nitroglycerin but resoPleating is refractory to nitroglycerin but resolves immediately when the stiff guidewire is withdrawnlves immediately when the stiff guidewire is withdrawn. .

Mistakes in Interpretation

Inadequate Number of ProjectionsInadequate Number of Projections Inadequate Injection of Contrast MaterialInadequate Injection of Contrast Material Superselective InjectionSuperselective Injection (fail to detect significant ostial ste (fail to detect significant ostial ste

nosis , the conus, sinus node arteries , LAD occluded ) nosis , the conus, sinus node arteries , LAD occluded ) Catheter-induced Coronary SpasmCatheter-induced Coronary Spasm ; possibly caused by m ; possibly caused by m

echanical irritation and a myogenic reflex; most common iechanical irritation and a myogenic reflex; most common in right coronary arteryn right coronary artery

Congenital Variants of Coronary Origin and DistributionCongenital Variants of Coronary Origin and Distribution (double ostia of the right coronary artery or origin of the ci(double ostia of the right coronary artery or origin of the circumflex artery or origin of the circumflex artery from righrcumflex artery or origin of the circumflex artery from right coronary artery)t coronary artery)

Myoardial BridgesMyoardial Bridges – coronary arteries occasion dip below t – coronary arteries occasion dip below the epicardial surface under small strips of myocardium. Oche epicardial surface under small strips of myocardium. Occur most in LAD and its diagonal branches. The key to reccur most in LAD and its diagonal branches. The key to recognition of these bridges is that the apparent localized stenognition of these bridges is that the apparent localized stenosis returns to normal during diastole. osis returns to normal during diastole.

Total occlusionTotal occlusion

Profiles in Coronary Artery Disease

Atypical Chest Pain with Normal Coronary Arteries

A 45 y/o male has a 30 pack-year history of cigarette smokiA 45 y/o male has a 30 pack-year history of cigarette smoking and mild systolic hypertension with ACEI medicationng and mild systolic hypertension with ACEI medication

Chest discomfort character: rest onset , emotion-induced , efChest discomfort character: rest onset , emotion-induced , effort-related , treadmill test showed negative. fort-related , treadmill test showed negative.

On cardiac catheterization, coronary angiography showed mOn cardiac catheterization, coronary angiography showed mild lesion in proximal circumflex artery . LAD and RCA werild lesion in proximal circumflex artery . LAD and RCA were free of disease. He suffered from chest pain with a very brie free of disease. He suffered from chest pain with a very brief episode of total occlusion of LCX. Pulmonary capillary pef episode of total occlusion of LCX. Pulmonary capillary pressure was 30 mmhg. Chest pain was subsided after 10 mg ressure was 30 mmhg. Chest pain was subsided after 10 mg sublingual nifedipine . sublingual nifedipine .

Example of coronary spasm , left side showed a diffuse mild lesion is present in the proximal circumflex on initial angiography Right side show after several injections, the patient developed chest pain and the artery narrowed. The symptoms and narrowing were relieved with sublingual nifedipine.

Stable Angina

A 55 y/o female complained of chest discomfort with exertA 55 y/o female complained of chest discomfort with exertion in stable pattern over 2 years. Hyperlipidemia , Family ion in stable pattern over 2 years. Hyperlipidemia , Family Hx: Father has a AMI at 50 years of age. She took B-blockHx: Father has a AMI at 50 years of age. She took B-blocker for angina which helped but did not eliminate her sympter for angina which helped but did not eliminate her symptoms . She was followed AHA diet . An exercise tolerance toms . She was followed AHA diet . An exercise tolerance test showed 2 mm of ST depression in inferior leads after 3 est showed 2 mm of ST depression in inferior leads after 3 minutes. Cardiac catheterization was done. minutes. Cardiac catheterization was done.

Normal LAD and circumflex arteries but an 80% eccentric Normal LAD and circumflex arteries but an 80% eccentric right coronary artery lesion. The patient was treated with dright coronary artery lesion. The patient was treated with directional atherectomy with excellent angiographic results irectional atherectomy with excellent angiographic results and resolution of exercise-induced ischemia and resolution of exercise-induced ischemia

Veterans Affairs Angioplasty Compared to Medcine (ACMVeterans Affairs Angioplasty Compared to Medcine (ACME) trial showed in the study of 212 patients with single-vesE) trial showed in the study of 212 patients with single-vessel disease , sel disease , PTCA resulted in a reduction of anginal symptPTCA resulted in a reduction of anginal symptoms compared with medical therapy at a month (50% VS 2oms compared with medical therapy at a month (50% VS 24% angina free, respectively)4% angina free, respectively) and and 6 months later (64% VS 6 months later (64% VS 45%)45%). .

The Atorvastatin Versus Revascularization Therapy (AVEThe Atorvastatin Versus Revascularization Therapy (AVERT) showed aggressive lipid lowering to a low-density lipoRT) showed aggressive lipid lowering to a low-density lipoprotein(LDL) level of 78 mg.dl has a protein(LDL) level of 78 mg.dl has a greater reduction in hgreater reduction in hospitalization for recurrent ischemia compared with PTCA.ospitalization for recurrent ischemia compared with PTCA.

Examples of lesion regression taken from the Familial Atherosclerosis Treatment Study (FATS). The top row of images were obtained before lipid-lowering therapy and the bottom row were obtained 2.5 years later.

Examples of a single-vessel intervention in a patient with stable angina . An 80% eccentric right coronary artery lesion was treated with directional atherectomy with an excellent angiographic result.

Unstable Angina

A 72 y/o male had undergone CABG 13 years ago with saA 72 y/o male had undergone CABG 13 years ago with saphenous vein grafts placed to two obtuse marginals and Lphenous vein grafts placed to two obtuse marginals and LAD artery. He undergone reoperation 8 years ago with a leAD artery. He undergone reoperation 8 years ago with a left internal mammary graft being placed to the LAD artery ft internal mammary graft being placed to the LAD artery and saphenous vein grafts being placed to the obtuse margiand saphenous vein grafts being placed to the obtuse marginal and to posterior descending artery. However recurred cnal and to posterior descending artery. However recurred chest pain and EKG showed inferiorlateral ST-segment deprhest pain and EKG showed inferiorlateral ST-segment depression. ession.

Despites of heparinization, intravenous nitroglycerin, and Despites of heparinization, intravenous nitroglycerin, and maximal medical therapy for 4 days , he still felt chest pain.maximal medical therapy for 4 days , he still felt chest pain. So catheterization was done. So catheterization was done.

Acute Myocardial Infarction (Case 1)

A 70 y/o female suffered from chest pain at rest . EKG shoA 70 y/o female suffered from chest pain at rest . EKG showed nonspecific change. Hyperlipidemia Hx. He was admiwed nonspecific change. Hyperlipidemia Hx. He was admitted and treated with heparin and aspirin. Titrate B-blocker.tted and treated with heparin and aspirin. Titrate B-blocker. However, the second day he suffered from chest pain and However, the second day he suffered from chest pain and refractory to aggressive medical treatment. F/U EKG showrefractory to aggressive medical treatment. F/U EKG showed ST elevation in I, aVL , V6. 1-2 mm. So under the impred ST elevation in I, aVL , V6. 1-2 mm. So under the impression of acute myocardial infarction, he was rushed to takession of acute myocardial infarction, he was rushed to take to cath room. e to cath room.

The catheterization showed a totally occluded circumflex oThe catheterization showed a totally occluded circumflex obtuse marginal branch . Primary PTCA was done with restbtuse marginal branch . Primary PTCA was done with restoration of TIMI 3 and minimal residual stenosis. oration of TIMI 3 and minimal residual stenosis.

Acute Myocardial Infarction (Case 2)

A 56 y/o man with chest discomfort that awoke from sleep 1 hour befoA 56 y/o man with chest discomfort that awoke from sleep 1 hour before admission. The initial BP at ER showed 92/54 mmhg. EKG showed re admission. The initial BP at ER showed 92/54 mmhg. EKG showed sinus bradycarida(HR: 52/min) with 2 mm of ST elevation in lead II,IIsinus bradycarida(HR: 52/min) with 2 mm of ST elevation in lead II,III, aVF. Hepain and treated with tPA 100mg over 90 mins. Besides, rigI, aVF. Hepain and treated with tPA 100mg over 90 mins. Besides, right side EKG showed 1mm ST elevation in the right precordial lead . Hht side EKG showed 1mm ST elevation in the right precordial lead . However after nitroglycerin, BP dropped and Ivf challenge. The patients owever after nitroglycerin, BP dropped and Ivf challenge. The patients still has persisted chest pain noted after tPA 60 mins. So catheterizatiostill has persisted chest pain noted after tPA 60 mins. So catheterization was done. n was done.

The angiography showed an ulcerated eccentric 90% stenosis of right The angiography showed an ulcerated eccentric 90% stenosis of right coronary artery with TIMI 2 that was collateralled by LAD. However, coronary artery with TIMI 2 that was collateralled by LAD. However, he suffered from chest pain noted 6 hours later and repeat catheterizatihe suffered from chest pain noted 6 hours later and repeat catheterization and showed a total occlusion of the right coronary artery, which waon and showed a total occlusion of the right coronary artery, which was treated by PTCA with restoration of TIMI 3 and 30% stenosis . s treated by PTCA with restoration of TIMI 3 and 30% stenosis .

Thank You !