Coronary Angioplasty (cont.)
Daniel Lee Kulick, MD, FACC, FSCAI
Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
- Heart Disease Slideshow Pictures
- Medical Illustrations of the Heart Image Collection
- Take the Heart Disease Quiz!
- Find a local Cardiologist in your town
What medications treat coronary artery disease?
Angina medications reduce the heart muscle's demand for oxygen in order to compensate for the reduced blood supply, and also may partially dilate the coronary arteries to enhance blood flow. Three commonly used classes of drugs are the nitrates, beta blockers, and calcium blockers.
Examples of nitrates include:
- isosorbide (Isordil),
- isosorbide mononitrate (Imdur), and
- transdermal nitrate patches.
Examples of beta blockers include:
- propranolol (Inderal),
- atenolol (Tenormin), and
- metoprolol (Lopressor).
Examples of calcium blockers include:
- nifedipine (Procardia, Adalat),
- verapamil (Calan, Verelan, Verelan PM, Isoptin, Isoptin SR, Covera-HS),
- diltiazem (Cardizem, Dilacor, Tiazac), and
- amlodipine (Norvasc).
A newer fourth agent, ranolazine (Ranexa) is of value.
Many people benefit from these angina medications and experience reduction of angina during exertion. When significant ischemia still occurs, either with ongoing symptoms or with exercise testing, coronary arteriography is usually performed, often followed by either percutaneous coronary intervention or CABG.
Individuals with unstable angina have severe coronary artery narrowing and often are at imminent risk of heart attack. In addition to angina medications, they are given aspirin and the intravenous blood thinner, heparin. A form of heparin, enoxaparin (Lovenox), may be administered subcutaneously, and has been demonstrated to be as effective as intravenous heparin in those with unstable angina. Aspirin prevents clumping of blood clotting elements called platelets, while heparin prevents blood from clotting on the surface of plaques. Potent IV antiplatelet agents ("super aspirins") are also available to help initially stabilize such individuals. While people with unstable angina may have their symptoms temporarily controlled with these potent medications, they are often at risk for the development of heart attacks. For this reason, many people with unstable angina are referred for coronary angiography, and possible percutaneous coronary intervention or CABG.
Percutaneous coronary intervention can produce excellent results in carefully selected patients who may have one or more severely narrowed artery segments which are suitable for balloon dilatation, stenting, or atherectomy. During percutaneous coronary intervention, a local anesthetic is injected into the skin over the artery in the groin or wrist. The artery is punctured with a needle and a plastic sheath is placed into the artery. Under X-ray guidance (fluoroscopy), a long, thin plastic tube, called a guiding catheter, is advanced through the sheath to the origin of the coronary artery from the aorta. A contrast dye containing iodine is injected through the guiding catheter so that X-ray images of the coronary arteries can be obtained. A small diameter guide wire (0.014 inches) is threaded through the coronary artery narrowing or blockage. A balloon catheter is then advanced over the guide wire to the site of the obstruction. This balloon is then inflated for about one minute, compressing the plaque and enlarging the opening of the coronary artery. Balloon inflation pressures may vary from as little as one or two atmospheres of pressure, to as much as 20 atmospheres. Finally, the balloon is deflated and removed from the body.
Intracoronary stents are deployed in either a self-expanding fashion, or most commonly they are delivered over a conventional angioplasty balloon. When the balloon is inflated, the stent is expanded and deployed, and the balloon is removed. The stent remains in place in the artery. Atherectomy devices are inserted into the coronary artery over a standard angioplasty guide wire, and then activated in varying fashion, depending on the device chosen.
CABG surgery is performed to relieve angina in those whose illness has not responded to medications and are not good candidates for PCI. CABG is best performed in patients with multiple blockages in multiple locations, or when blockages are located in certain arterial segments which are not well-suited for percutaneous coronary intervention. CABG is often also used in patients who have failed to attain long-term success following one or more percutaneous coronary intervention procedures. CABG surgery has been shown to improve long- term survival in people with significant narrowing of the left main coronary artery, and in those with significant narrowing in multiple arteries, especially in cases of decreased heart muscle pump function.
Get the latest treatment options.