Angiography of a patient who had redo coronary artery bypass grafting in 1987. He had three grafts and has a recurrence of angina.
The following LAO angiogram shows?
Anatomy common to angiography for graft studies. These images are a particularly good example as graft markers (radio-opaque circles) have been placed and show the graft positions relative to each other in LAO and RAO view. Right coronary artery grafts are placed above the native RCA on the aorta. The graft is best engaged in the LAO view with the catheter pointing towards the left of the field of view. In this case a stump is revealed at the point of the marker.
Left coronary system grafts (commonly diagonal, obtuse marginal, or intermediate. vein grafts to the LAD are now uncommon due to the LIMA) are placed sequentially above the native left coronary system. In the RAO view the grafts are engaged with the catheter pointing to the right of the field of view.
The Aortogram in LAO shows?
The aortogram tests basic aortic arch, head, and neck anatomy. The first branch from the right (1) is the brachiocephalic (‘innominate’) artery which gives off the right subclavian artery (origin of the RIMA) and right common carotid artery. The middle branch (2) is the left common carotid artery. The third branch (3) is the left subclavian artery which give off the LIMA.
You are referred a 40-year-old lady with left arm pain. She had a single episode after running for a bus with shopping, which subsided after 5 minutes. She has never previously had exertional chest discomfort. Resting ECG is normal and 8 hours high-sensitivity troponin is negative. She has a BMI of 33 and diet-controlled type 2 diabetes mellitus but is not hypertensive.
What do you recommend?
This woman has an intermediate risk of coronary artery disease (30–60%). She has had a single episode of possible angina but ACS is ruled out. A functional test (stress echo, stress MRI, or nuclear perfusion scan) is the most appropriate form of risk stratification and this can be completed as an outpatient.
A 25-year-old male developed sharp central chest pain and palpitations after drinking three cans of energy drink whilst revising for exams. The symptoms were ongoing when he initially attended the ED, and an ECG showed a sinus tachycardia with no ST change. The pain subsided shortly afterwards. He is normally fit and well. His father recently had a myocardial infarction at the age of 62. All observations and examination are normal. Troponin and D-dimer tests were negative.
What would you recommend?
This patient currently has a very low risk of coronary disease (<10%) and so no further ischaemic stratification is necessary. The cause of the symptoms appears to be related to the sinus tachycardia and energy drink. Aggressive primary prevention is, of course, paramount in view of the family history.
One of your patients has small vessel coronary disease which is not suitable for revascularization. They are still experiencing class 2 angina particularly in the evening despite bisoprolol 10 mg od. Blood pressure is 135/90 mmHg.
What would you recommend next?
NICE guidelines recommend a beta-blocker or a calcium-channel antagonist as first line with the addition of the other class as second line. Third-line agents are long-acting nitrate, iviabradine, nicornadil, or ranolazine. ESC guidelines marginally select beta-blockers over calcium-channel agonists as first line (evidence is stronger post-MI). Second line in combination with the beta-blocker is a calcium-channel blocker or long-acting nitrate. If beta-blockers are contraindicated/not tolerated any class agent can be considered in combination. Bisoprolol is long acting but atenolol 50 mg bd may be better than 100 mg od because of its shorter half-life. There is clearly blood pressure reserve for amlodipine and the patient may also benefit from improved BP control.
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