V. N. KARAZIN KHARKIV NATIONAL UNIVERSITY
PROPAEDEUTICS OF INTERNAL MEDICINE AND PHYSICAL REHABILITATION
A CLINICAL CASE OF SUCCESSFUL BALLON ANGIOPLASTY IN THE REMOTE PERIOD IN A MIDDLE-AGED PATIENT AFTER
LATE STENT RESTENOSIS
Speaker: student of IV course, gr.409, Roni Morani
Scientific supervisors: D. Y. Pavlova, Assistant Professor T. V. Zolotarova, Assistant Professor Head of department: M. S. Brynza, Candidate of Medicine
MYOCARDIAL REVASCULARIZATION AFTER ACUTE MYOCARDIAL INFARCTION
● Myocardial revascularization procedures represent important treatment options for patients with acute and chronic coronary artery disease (CAD).
● Acute myocardial infarction (MI) was identified nearly 50 years ago as a coronary occlusive event resulting from atherosclerotic plaque rupture and thrombosis. This mechanistic understanding was essential to the development of reperfusion therapy for treating ST-segment elevation MI (STEMI).
● The treatment of STEMI has advanced since the introduction of reperfusion therapies.
● Mechanical reperfusion with primary percutaneous coronary intervention is now the standard of care.
● The introduction of bare metal stents (BMS) was a significant milestone in the evolution of percutaneous coronary intervention. Soon after it was apparent that these stents led to in-stent restenosis (ISR), which requires repeat revascularization.
● Restenosis is defined as a reduction in lumen diameter after percutaneous coronary intervention (PCI), either with or without stent implantation.
● In-stent restenosis currently defined as a >50% stenosis of a previously stented segment, occurs in 30% of all patients receiving BMS.
BALLOON ANGIOPLASTY FOR THE TREATMENT OF CORONARY IN-STENT RESTENOSIS
Balloon angioplasty (BA) was one of the earliest strategies used in patients experiencing ISR. The procedure is technically straightforward and consistently associated with satisfactory acute results and a very low incidence of complications.
Currently available therapeutic modalities, such as drug-coated balloons (DCB) and drug-eluting stents (DES) provide the best clinical and angiographic results in patients with ISR. However, the field is rapidly evolving. Further studies are required to identify clinical and anatomic characteristics that may help to refine selection and tailor available therapeutic strategies to improve clinical outcomes.
OUR PATIENT PROFILE
•51 years old (01.06.1968)
•Lives in a village
•Hospitalized on 18.10.18 to the cardiological
department of City Clinical Hospital № 8
• Disruptions of the heart beats and heart palpitations which are related to physical activity
• Shortness of breath when walking (observed during physical exertion, while ascending the staircase to the fifth floor), disappearing after the rest
• Unstable blood pressure (increasing of BP in the range of 160/90 mmHg – 180/100 mmHg, despite taking hypotensive drugs, –
MEDICAL HISTORY 1.2
Hypertension for 10 years with the maximum blood pressure (BP) over 180/100 mm Hg
The usual BP is about 140/90 mm Hg (antihypertensive drugs – Bisoprolol 5 mg, Ramipril 5 mg
Since 2009, the blood pressure measured noted to be consistently elevated in the range of 160/100 mmHg – 180/100 mmHg on three occasions
On August 18 2016 was diagnosed with Non-Q-wave myocardial infarction (left ventricular posterior wall myocardial infarction)
On September 7 2016 was performed coronary angiography and
MEDICAL HISTORY 2.2
● On September 18 2016 was performed coronary angiography with implantation of two non–drug-eluting stents
● On February 2017 symptoms of progressive unstable angina, diagnosed in-stent restenosis, completed balloon angioplasty
● On October 2018 admitted to the cardiological department with complaints:
palpitations that were connected with physical exercises; breathlessness while ascending to the fifth floor
● Hospitalized with the diagnoses: Ischemic Heart Disease. Postinfarction (posterior STEMI of LV 18.08.16) cardiosclerosis. Arterial Hypertension, stage III, grade 2, high risk. Chronic heart failure, NYHA class II, stage С, with preserved EF (50%). Patient hospitalized to the cardiological department of CCH №8 for examination and correction of the treatment.
MEDICAL HISTORY - CORONARY ANGIOGRAPHY
A - Angiography showed the left anterior descending coronary artery stenosis (50%) B - the left circumflex artery occlusion of the distal segment
C - occlusion of the obtuse marginal branch
D - During angiography performed recanalization of occlusion of the distal segment with Ryujin balloon 1.5 cm * 15 mm with implantation of two Bare – Metal Stents: Chroma 2.25 * 14 mm and Chroma 2.75 * 24 mm.
MEDICAL HISTORY - BALLOON ANGIOPLASTY (17.02.17)
Patient admitted to the cardiological department with symptoms of progressive unstable angina.
The Coronary Angiography revealed restenosis of a stented segment to the level of subocclusion, with chronic occlusion of the obtuse marginal branch. The right coronary artery was without significant hemodynamic disturbances.
During angiography performed angioplasty of the restenosis with NC
Sprinter ballon 2.5 * 15 mm.
HISTORY OF LIFE
• Was born in a full family, developed according to age
• Denies tuberculosis, diabetes, malaria, viral hepatitis, sexually transmitted diseases and AIDS
• Denies allergic reactions to drugs
• Denies alcohol consumption
• Sedentary lifestyle
• Hasn’t checked his lipid and glucose profile over 6 months
• Hereditary - no family history of cardiovascular disease
OBJECTIVE STATE: 1.2
• The general condition is satisfactory, consciousness is clear, emotionally stable, optimistic mood
• Hypersthenic, height 176 cm, weight 80 kg, BMI = 25.8 kg / m2
, waist-to-hip ratio 0,90
• Skin, visible mucous membranes are pale pink and clean
• Peripheral lymph nodes are not palpable
• The thyroid is not palpable
OBJECTIVE STATE: 2.2
• Respiratory System: Pulmonary percussion – resonant sound, auscultation - vesicular breathing , no adventitious sounds
• Cardiovascular system: Heart borders extended to the left on 1,5 cm of midclavicular line, HR =76 bpm, regular. Ps= 76 bpm. No pulse deficiency
• Heart sounds are muted, accent of the II tone above the aorta.
• BP dextr = BPsin= 140/80 mm Hg (on the background of antihypertensive therapy)
• Gastrointestinal system: Abdomen is soft, painless, symmetrical, no discrepancies of the abdominal muscles.
• No visible peristalsis.
• Liver edge is smooth, painless , palpated 2 cm below the costal arch.
• Spleen and pancreas are not palpable
• No pitting oedema
Examination, completed in the hospital
• General blood test
• General urine test
• Biochemical blood test (Liver and renal function tests)
• Blood lipid spectrum
• Blood glucose level
• 24 hours electrocardiography monitoring
• Stress test ( Cycle Ergometer test)
Recommended additional examination
• Blood glucose level (Hb A1c)
• Random glucose test
• Blood electrolytes (K, Na)
• Cardiologist consultation
• Endocrinologist consultation
Ultrasonography of the abdomen (liver, gallbladder, pancreas, kidneys)
This tests wasn’t completed for financial reasons.
COMPLETE BLOOD TEST (19.10.18)
MEASURE RESULT RATE
Hemoglobin 154 M 130 - 160 g / l
Erythrocytes 5.04 M 4.0-5.0 T / l
Color index 1.06 0,85 – 1,15
Leukocytes 6.9 4,0 – 9,0 g/L
ESR 11 M 2-12 mm/h
Platelets 260 160-320 g/L
Band Neutrophils 1 1-6 %
Segmented Neutrophils 52 47-72 %
Eosinophils 1 0,5-5,0%
Basophils 0 1-1,0 %
Monocytes 3 3-11 %
Lymphocytes 43 19-37%
GENERAL URINE TEST (19.10.18)
MEASURE RESULT NORMAL RANGE
SPECIFIC GRAVITY 1.012 1,001-1,040
REACTION 6,8 5,0-7,0
PROTEIN 0.020 to 0.033 g / l
GLUCOSE 0 Absent
LEUCOCYTES 1-2 6-8
EPITHELIUM TRANSITION Not detected Not detected
BACTERIA Not detected Not detected
BIOCHEMICAL BLOOD TEST (19.10.18)
MEASURE RESULT NORMAL RANGE
AsAt 27,8 <37 u/L
AlAt 60 <41 u/L
Fasting glucose 6,2 4,2-6,1 mmol/l
Creatinine 91,5 80-115 mcmol/L
Conclusion: elevated transaminases, hyperglycemia.
GLOMERULAR FILTRATION RATE
RESULT NORMAL RANGE
GFR (Cockroft - Gault) 85.4 >90 ml/min/1.73m2
GFR (CKD-EPI) 83.2 >90 ml/min/1.73m2
GFR (MDRD) 81 >90 ml/min/1.73m2
Conclusion: According to GFR level, mildly reduced kidney function.
BLOOD LIPID SPECTRUM (19.10.18)
MEASURE RESULT RATE
Total Cholesterol 3,7 ≤ 5,2 mmol / l (<4,5)
VLDL 0,97 <1,0 mmol / l
LDL 1,92 <3,5 mmol / l
HDL- cholesterol levels 0,81 >0,9 mmol / l
Triglycerides 2,13 ≤2,3 mmol / l
Coefficient of atherogenicity 3,57 to 3,0 mmol/l
Conclusion: increased coefficient of atherogenicity due to the level of HDL
rhythm, normal heart axis, with heart rate 54 bpm. Posterior wall repolarization interruption.
24 HOURS ELECTROCARDIOGRAPHY MONITORING (18.10.18)
Result: during 24-hours monitoring registered sinus rhythm, supraventricular premature contractions (total 210); short supraventricular tachycardia episodes;
monomorphic ventricular premature contractions (total 10). Daily heart rate - 55 beats/min (bpm), night heart rate - 55 beats/min (bpm).
Principles of diagnostic testing
CYCLE ERGOMETER STRESS TESTING FOR IDENTIFICATION OF SIGNIFICANT CORONARY ARTERY DISEASE (19.10.18)
• The bicycle ergometer test was carried out according to the incremental workloads calibrated in watts (W). The protocol started with a power output of 10W/minutes, followed by increases of 25 W/min. every 3 min.
• The test was negative. Stopped after reaching the 150 W/min, the appearance of chest pain, heavy chest pressure, difficulty in breathing. The duration of the last step – 1 min. 30 sec.
• After stopping the test ECG showed ST segment without specific changes, registered infrequent ventricular extrasystoles without signs of coronary insufficiency, blood pressure - 210/100 mmHg, heart rate - 110 beats/min (bpm).
• Period of restitution was without specific features. Blood pressure recovered in 5 min. to 120/80 mmHg, chest pain relieved in 2 min.
Name Result Normal
1) Aorta 37 mm. 20-37 mm
2) Aortic Valve Opening 18 mm 17-26 mm
3) Left Atrium Antero-posterior size: 50 mm To 38 mm 4) Mitral Valve No regurgitation
5) Posterior wall of the LV
11 mm. Contraction – normokinetic. 6-11 mm
6) LV end-diastolic diameter
58 mm 46-57 mm
7) LV end-systolic diameter
43 mm 31 - 43 mm
Name Result Normal
8) Interventricular septum 11 mm 6-11 mm
9) Right Ventricle D.: 24 mm D.: (9-26 mm). Thickness of the wall 3-6 mm
10) Right Atrium 38 mm <44 mm
11) Tricuspid Valve No regurgitation
10)Ejection Fraction 50% 55-78%
Conclusion: sclerotic changes of aortic walls, aortic valve.
Dilation of the left ventricle and atrium. Left ventricular hypertrophy.
BASIC CLINICAL SYNDROMES
• Atherosclerosis (sclerotic changes of aortic valve, mild atherosclerotic aortic stenosis)*
• Arterial hypertension *
• Arrhythmias (permanent (constant) AF)
• Heart failure
• Hypertensive heart (LVH, atrial enlargement, increased diastolic stiffness)*
• Hepatomegaly, liver steatosis
• Erythrocytosis, hemoconcentration
• Hyperglycemia / glycosuria syndrome*
• Obesity: BMI = 25.8 kg / m2, waist-to-hip ratio 0,90*
• * - features of metabolic syndrome
The clinical diagnosis according to current
(kg/m2) Underweight <18.5 Healthy
18.5-24.9 Overweight 25-29.9 Obese 30-34.9 Severely
CATEGORIES WAIST-TO-HIP RATIO
Health risk Men
Low 0.80 or lower
CLASSIFICATION OF OVERWEIGHT AND OBESITY AND WAIST-TO-HIP RATIO
DEFINITIONS AND CLASSIFICATION OF OFFICE BLOOD PRESSURE LEVELS (MMHG)
Category Systolic Diastoli c
Optimal <120 and <80 Normal 120-129 and/o
High normal 130-139 and/o r
Grade 1 hypertension
140-159 and/o r
Grade 2 hypertension
160-179 and/o r
Grade 3 hypertension
≥180 and/o r
Isolated systolic hypertension
≥140 and <90
http://www.esh2013.org/wordpress/wp-content/uploads/2013/06/ESC-ESH-Guidelines-2013.pdf Stage The degree of target organ damage
I Objective changes in the target organs are absent
II There is objective evidence of target organ damage without symptoms with their hand or dysfunction:
Left ventricular hypertrophy (on ECG, ultrasound, Ro) Generalized narrowing of retinal arteries
Microalbuminuria and / or a small increase in serum creatinine (y m. - 115 - 133 mmol / L at x. - 107 - 124 mmol / l) Carotid artery disease - a thickening of the intima-media> 0.9 mm or the presence of atherosclerotic plaques
III There is objective evidence of target organ damage with symptoms from their side and impaired heart - myocardial infarction, heart failure II A - III stage; brain - stroke, transient ischemic attack, acute hypertensive encephalopathy, vascular dementia; fundus - hemorrhage and retinal exudates with papilledema the optic nerve or without; kidney - concentration of plasma creatinine in males> 133 umol / L, y Women> 124; vessels - dissecting aortic aneurysm; peripheral arterial occlusion
Functional capacity Objective Assessment
Class I - No symptoms and no limitation in ordinary physical
activity, e.g. shortness of breath when walking, climbing stairs etc. Class A. No objective evidence of cardiovascular disease.
Class II - Mild symptoms (mild shortness of breath and/or
angina) and slight limitation during ordinary activity. Class B. Objective evidence of minimal cardiovascular disease.
Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20—100 m).Comfortable only at rest.
Class C. Objective evidence of moderately severe cardiovascular disease.
Class IV - Severe limitations. Experiences symptoms even while at
rest. Mostly bedbound patients. Class D. Objective evidence of severe cardiovascular disease.
THE NEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL CLASSIFICATION (FUNCTIONAL CAPACITY) OF CHF
AMERICAN HEART ASSOCIATION HEART FAILURE STAGES
COMPLETE DIAGNOSIS OF OUR PATIENT:
OUR CLINICAL DIAGNOSIS Main:
ISCHAEMIC HEART DISEASE. POSTINFARCTION (POSTERIAL STEMI OF LV 18.08.16) CARDIOSCLEROSIS.
7.08.16 CORONARY ANGIOGRAPHY, 27.09.16 CORONARY ARTERY STENTING WITH TWO BARE-METAL STENTS, 17.02.17 BALLOON ANGIOPLASTY AFTER STENT RESTENOSIS.
(ATHEROSCLEROSIS OF THE AORTA)
ESSENTIAL ARTERIAL HYPERTENSION STAGE III, 2 GRADE. HYPERTENSIVE HEART (LVH)
CHRONIC HEART FAILURE WITH PRESERVED LEFT VENTRICLE EJECTION FRACTION ( EF- 50%), II CLASS, STAGE C NYHA.
VERY HIGH ADDED TOTAL CV RISK Co-morbidity: Pre- diabetes?
HEALTH FACILITY DIAGNOSIS Main:
ISCHAEMIC HEART DISEASE. ANGINA PECTORIS CLASS III.
POSTINFARCTION (POSTERIAL STEMI OF LV 18.08.16) CARDIOSCLEROSIS.
SYSTEMIC ATHEROSCLEROSIS (ATHEROSCLEROSIS OF THE AORTA)
ARTERIAL HYPERTENSION STAGE III, 3 GRADE
HYPERTENSIVE HEART (LVH)
• Lifestyle modification
• Medical intervention
THERAPEUTIC LIFESTYLE CHANGES
PARAMETER TREATMENT GOAL
(for overweight and obese patients) Reduce by 5% to 10%
• At least 150 minutes of moderate-intensity physical activity (for example, 30 minutes, 5 days a week),
• At least 75 minutes of vigorous-intensity physical activity (for example, 25 minutes, 3 days a week); or
• A combination of moderate- and vigorous-intensity aerobic activity, and
• At least 2 days of moderate- to high-intensity muscle- strengthening activities (such as resistance
weight training) for additional health benefits
• Vegetables, fruits, and whole grains
• Legumes and nuts
• Low-fat dairy products
• Low-fat poultry (without the skin)
• Fish and seafood
• Nontropical vegetable oils
TREATMENT STRATEGY 1.2.
BP target – 130-139/85-89 mm Hg
n LDL-C target of 1.8 mmol/L (70 mg/dL)
Glycated Hemoglobin (HbA1c) to ,7.0% (53 mmol/mol)
According to the ESC Clinical Practice Guidelines 2013, Management of Stable Coronary Artery Disease
HEALTH FACILITY TREATMENT
• Bisoprolol 5 mg in the morning
• Enalapril 5 mg in the morning
• Aspirin 100 mg in the evening
• Clopidogrel 75 mg in the evening
• Atorvastatin 40 mg in the evening IV therapy
•Meldonium 500mg / 5.0 ml, N10
•Angiotensin-converting enzyme (ACE) inhibitor-Ramipril 5 mg in the morning
•Diuretic – Eplerenone 25 mg, in the morning
•Β- blocker-Bisoprolol 5 mg in the morning (target HR – 60 b/m)
•Antiplatelet therapy - Aspirin 100 mg in the evening
•Antiplatelet agent - Clopidogrel 75 mg in the evening
•Statin- Rosuvastatin 20 mg in the evening
CONTROL OF COMPLIANCE TO MEDICAL
RECOMMENDATIONS (diet, weight, physical activity,
drug treatment) !
RECOMMENDATIONS FOR FURTHER EXAMINATION
• Exercise ECG
• 24h-ECG monitoring
• Daily glycemic profile, Glucose tolerance test, HbA1C, consultation of Endocrinologist
• Echocardiography for evaluation of diastolic function of LV
• Lipid profile (LDL), ALT (liver)
•Prognosis for life - non-compliance to doctor's appointments – non-
•The prognosis for recovery -
● In our clinical case, according to the result of cardiac stress test, when veloergometer cycle test showed no signs of myocardial ischemia, balloon angioplasty has proven to be an effective method of In-stent restenosis treatment.
● Considering that Diabetes mellitus has a role in foster the In-stent restenosis process, further diagnostic recommended: HbA1c, fasting plasma glucose and postprandial glucose level control, glucose tolerance test.
● To clarify the segmental heart contractility, we recommend additionally a Stress-echo test and Speckle tracking echocardiography.
● Repeat Coronarography in case of cardiac ischemia signs.