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Consider when patients are not responding to the drugs
Too many side effects of the drugs
Patient has type of CAD that respond esp. well to interventions
Percutaneous coronary intervention (PCI)
Done under fluoroscopy
Balloon tipped catheter into peripheral artery
Balloon is inflated once into the coronary vessel
This helps by increasing the size of the lumen, which increases perfusion and O2 supply. The effect is to compress the plaque and stretch the vessel underneath. Drawbacks = most patients have restenosis with in a short period of time.
Stents can now be placed at the time of PCI which reduces the chance of restenosis. Left permanently in the vessel and acts as a scaffold to maintain patency.
Problem: thrombogenicÆ must give oral anti-platelet agents afterward.
Also, at time of PCI, we can attempt to get rid of some of the plaque: directional coronary atherectomy shaves the plaque down and fragments are collected. Rotational atherectomy uses a spinning burr to get rid of the plaque.
PCI has not been shown to reduce the risk of MI or death from CAD.
Coronary Artery Bypass Graft (CABG)
Native veins are grafted onto the coronary vessels to bypass the obstruction (saphenous vein is commonly used)
Arterial grafts can also be used, by reconnecting the internal mammary artery to the coronary vessel
The arterial grafts tend to stay patent longer—more resistant to atherosclerosis.
Plan for patient with chest pain: First, get a good history. Ask all the questions about quality of pain/discomfort, location, accompanying symptoms, precipitating factors, what made it go away.
After you establish that the patient’s history is consistent with that of angina, you will want to do an ECG. Although you might not find anything if the patient is no longer experiencing the discomfort, it’s an easy test that could potentially show something.
Once you see that the ECG is not helpful, you will want to get an exercise stress test if the patient is able to exercise. You find ST segment depression, so you have a potential diagnosis.
Begin by counseling the patient on smoking cessation, diet and exercise. Then move into prescribing medications. First, aspirin. Then, prescribe NTG for acute attacks. Ask about asthma and then prescribe a beta blocker and an ACE inhibitor. Look at the patient’s LDL level and consider offering a statin. Keeping cost of medications in your mind, maybe you could wait on the Ca-channel blocker, as its effectiveness has not been proven.