Transcript Unstable angina and arterial hypertension

Unstable angina and arterial
hypertension
Leszek Kinasz, MD
American Heart of Poland
Ustron, Poland
Clinical data
Female, 59 years old
 Unstable angina (CCS class 4)
 Hypertension since 1999, currently required
4 drugs (ACEI, beta-blocker, duretic,
calcium channel blocker)
 Hypercholesterolaemia
 History of pulmonary oedema
 BMI 35
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Clinical data
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RR 220/120
HR 64/min
Pulmonary congestion
EKG: ST depression and negative T wave in
inferior and lateral leads
UKG: LVEF 55%, hypokinesia of inferior
segments, MVI(+)
Lab tests: CPK, CPK-MB, Troponin I - normal,
Creatinine 1.4 mg%
Coronary angiography (CAG)
RCA LAO60:
99% lesion in distal segment
type B2
LCA RAO30, Caud 15
Normal epicardial segments
PCI:
7F JR guiding cath, 0,014” BMW wire,
RCA LAO60:
predilatation and stent positioning
(BX Velocity 3.0x18 mm)
After stenting:
max. pressure 18atm
After PCI:
Persisted chest pain and ST/T changes on
the EKG monitor
 RR 200/120
-a rigorous treatment of hypertension
(NTG i.v. and i.a., Furosemid i.v.,
nifedipine s.l.) without effect on angina
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What is a cause of the chest pain?
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Occlusion of a small AM branch?
AM
What is a cause of the chest pain?
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Hypertension?
If so, what should be done next?
1. More intensive pharmacological
treatment
2. Further diagnosis of hypertension
Renal angiography
Right renal artery
Left renal artery
Angio performed in AP view,
with Right Judkins catheter used previously for PCI
Renal stenting as a one-stage
procedure with PCI:
Renal stenting:
Guiding catheter: 7F, Judkins Right
Wire: 0,014” BMW
Stent: Corinthian 6.0mm, 14 atm,
Left renal artery after stenting
Diagnostic cath, PCI and Renal
Stenting as one-stage procedure:
Coronary diagnostic catheters:
 No of wires:
 No of guiding catheters:
 No of balloon catheters:
 No of stents:
 Contrast:
Ultravist
 X-Ray exposition
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2
1
1
1
2
190 ml
10.5 min.
After the procedure
No chest pain
 Arterial pressure: 150/90
 Resolution of ST/T changes in serial ECG
 Lab tests on the next day:
-cardiac enzymes in normal range
-serum creatinine 1.2 mg%
 Hospital stay:
36 hours
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Discussion:
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Symptoms suggesting renal artery stenosis (RAS)
in the presented patient:
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-short history of hypertension
-diastolic hypertension resisted to pharmacological
treatment
-the history of pulmonary oedema despite of
preserved global LVEF
CAD & RAS
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In 15% of patients undergoing CAG, a significant
RAS (>50%) can be found
No of narrowed
coronary arteries
0
1
2
3
LM
Risk
of RAS
8.8%
10.7%
17.6%
29,9%
39.0%
(The Duke University Experience)
RAS & Risk of MACE
No-RAS
RAS
p
13.8%
41%
0.01
58.3%
0.01
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AMI
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Revascularization 33.1%
(PTCA or CABG)
(The Duke University Experience)
The influence of renal stenting
on UA and CHF
N=48 pts
with UA or CHF and concomitant
uni- or bilateral RAS
Results:
After renal stenting resolution of symptoms in 88%
of patients during 8.4 months follow-up.
Am J Cardiol 1997;80:363-6
Influence of renal stenting on renal
function
2,5
2
1,5
Creatinine
1
0,5
0
0
6
12
24
36
Circulation 1998;98:642-7
48
months
Conclusions:
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Patients with angina and the history suggesting
RAS, coronary angiography should be always
followed by renal artery angiography.
Renal artery angiography and renal stenting can be
performed easily during CAG or PCI as a one
stage procedure at the low risk and low additional
cost.