Unstable angina and arterial hypertension

1
Unstable angina and arterial hypertension

• Leszek Kinasz, MD
• American Heart of Poland
• Ustron, Poland

2
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

3
Clinical data

• 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

4
Coronary angiography (CAG)
LCA RAO30, Caud 15 Normal epicardial segments
RCA LAO6099 lesion in distal segmenttype B2
5
PCI 7F JR guiding cath, 0,014 BMW wire,
RCA LAO60predilatation and stent
positioning (BX Velocity 3.0x18 mm)
After stenting max. pressure 18atm
6
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

7
What is a cause of the chest pain?

• Occlusion of a small AM branch?

AM
8
What is a cause of the chest pain?

• Hypertension?If so, what should be done
  next?1. More intensive pharmacological
  treatment2. Further diagnosis of hypertension

9
Renal angiography
Right renal artery
Left renal artery
Angio performed in AP view, with Right Judkins
catheter used previously for PCI
10
Renal stenting as a one-stage procedure with PCI
Renal stentingGuiding catheter 7F, Judkins
RightWire 0,014 BMW Stent Corinthian 6.0mm,
14 atm,
Left renal artery after stenting
11
Diagnostic cath, PCI and Renal Stenting as
one-stage procedure

• Coronary diagnostic catheters 2
• No of wires 1
• No of guiding catheters 1
• No of balloon catheters 1
• No of stents 2
• Contrast Ultravist 190 ml
• X-Ray exposition 10.5 min.

12
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

13
Discussion

• Symptoms suggesting renal artery stenosis
  (RAS)in the presented patient
• -short history of hypertension-diastolic
  hypertension resisted to pharmacological
  treatment-the history of pulmonary oedema
  despite of preserved global LVEF

14
CAD RAS

• In 15 of patients undergoing CAG, a significant
  RAS (gt50) can be foundNo of narrowed
  Riskcoronary arteries of
  RAS0 8.81 10.72 17.63 2
  9,9LM 39.0

(The Duke University Experience)
15
RAS Risk of MACE

• AMI
• Revascularization(PTCA or CABG)

• No-RAS RAS p
• 13.8 41 0.01
• 33.1 58.3 0.01

(The Duke University Experience)
16
The influence of renal stenting on UA and CHF

• N48 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 199780363-6
17
Influence of renal stenting on renal function
months
Circulation 199898642-7
18
Conclusions

• 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.