44443 ABC of Cardiology 22/10/03 10:54 am Page 1 Coronary artery disease causes severe disability and more death than any other disease in af(cid:223)uent societies. Medical conditions associated with this disease are angina, ischaemia, unstable angina, A ABC myocardial infarction, arrhythmias, heart failure, and sudden death. B C O In recent years, interventional cardiology, particularly percutaneous coronary intervention, has F progressed dramatically and undergone incredible evolution. In many countries, numbers of IN percutaneous coronary procedures now equal or exceed bypass surgery.. Although coronary T E intervention has held centre stage, major inroads in non-coronary percutaneous intervention have R V OF been made. E N T Much of the breathtaking momentum seen in interventional cardiology in recent years has been IO captured in this highly informative and well illustrated ABC of Interventional Cardiology. It will help N INTERVENTIONAL A the reader to make decisions on cardiac diagnosis and appropriate care, and to advise patients on the L bene(cid:222)ts that percutaneous intervention can offer. C A R Chapters include: D I ¥ Pathophysiology and investigation of coronary artery disease O CARDIOLOGY L ¥ Percutaneous coronary intervention O G ¥ Chronic stable angina: treatment options Y ¥ Acute coronary syndrome ¥ Percutaneous coronary intervention: cardiogenic shock ¥ Interventional pharmacotherapy ¥ Non-coronary percutaneous intervention ¥ New developments in percutaneous coronary intervention ¥ Percutaneous interventional electrophysiology ¥ Implantable devices for treating tachyarrhythmias ¥ Interventional paediatric cardiology Broad, and sometimes complex, aspects of interventional cardiology are presented in a clear, concise, and balanced manner. This easy to read text, supplemented by numerous images and graphics, will appeal to a broad readership, including medical students, family doctors, physicians, and cardiologists. Related titles from BMJ Books ABC of Antithrombotic Therapy ABC of Clinical Electrocardiography ABC of Heart Failure Cardiology Core Curriculum Cardiovascular Emergencies Education in Heart Evidence-based Cardiology Improving Outcomes in Chronic Heart Failure Mechanisms and Management of Cardiac Arrhythmias 100 Questions in Cardiology General Practice Cardiology G r e c h Edited by Ever D Grech www.bmjbooks.com ABC OF INTERVENTIONAL CARDIOLOGY For Lisa, Alexander, and Frances ABC OF INTERVENTIONAL CARDIOLOGY Edited by EVER D GRECH Consultant Cardiologist, South Yorkshire Cardiothoracic Centre, Northern General Hospital, Sheffield, UK © BMJ Publishing Group 2004 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2004 by BMJ Publishing Group Ltd, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1546 0 Cover shows coloured arteriogram of arteries of the heart. With permission from Science Photo Library. Typeset by BMJ Electronic Production and Newgen Imaging Systems Printed and bound in Spain by GraphyCems, Navarra Contents Contributors vi Preface vii Acknowledgements viii 1 Pathophysiology and investigation of coronary artery disease 1 Ever D Grech 2 Percutaneous coronary intervention. I: History and Development 5 Ever D Grech 3 Percutaneous coronary intervention. II: The procedure 8 Ever D Grech 4 Chronic stable angina: treatment options 12 Laurence O’Toole, Ever D Grech 5 Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction 16 Ever D Grech, David R Ramsdale 6 Acute coronary syndrome: ST segment elevation myocardial infarction 19 Ever D Grech, David R Ramsdale 7 Percutaneous coronary intervention: cardiogenic shock 22 John Ducas, Ever D Grech 8 Interventional pharmacotherapy 25 Roger Philipp, Ever D Grech 9 Non-coronary percutaneous intervention 29 Ever D Grech 10 New developments in percutaneous coronary intervention 33 Julian Gunn, Ever D Grech, David Crossman, David Cumberland 11 Percutaneous interventional electrophysiology 37 Gerry C Kaye 12 Implantable devices for treating tachyarrhythmias 41 Timothy Houghton, Gerry C Kaye 13 Interventional paediatric cardiology 45 Kevin P Walsh Index 49 v Contributors David Crossman Timothy Houghton Professor of Clinical Cardiology, Cardiovascular Research Registrar in Cardiology, Hull and East Yorkshire Trust, Castle Group, Clinical Sciences Centre, Northern General Hospital, Hill Hospital, Hull Sheffield Gerry C Kaye David Cumberland Consultant Cardiologist, Hull and East Yorkshire Trust, Castle Consultant Cardiovascular Interventionist, Ampang Puteri Hill Hospital, Hull Specialist Hospital, Kuala Lumpur, Malaysia Laurence O’Toole John Ducas Consultant Cardiologist and Physician, Royal Hallamshire Consultant Cardiologist, Health Sciences Centre and Hospital, Sheffield St Boniface Hospital, Winnipeg, Manitoba and Associate Professor, University of Manitoba, Winnipeg, Canada Roger Philipp Fellow in Interventional Cardiology, Health Sciences Centre Ever D Grech and St Boniface Hospital, Winnipeg, Manitoba, Canada Consultant Cardiologist, South Yorkshire Cardiothoracic Centre, Northern General Hospital, Sheffield, UK David R Ramsdale Consultant Cardiologist, Cardiothoracic Centre, Liverpool Julian Gunn Senior Lecturer and Honorary Consultant Cardiologist, Kevin P Walsh Cardiovascular Research Group, Clinical Sciences Centre, Consultant Paediatric Cardiologist, Our Lady’s Hospital for Northern General Hospital, Sheffield Sick Children, Crumlin, Dublin, Republic of Ireland vi Preface It is only 26 years since the first percutaneous transluminal coronary angioplasty (PTCA) was carried out by the pioneering Swiss radiologist, Andreas Greuntzig, heralding the dawn of interventional cardiology. In this short time, interventional cardiology has overcome many limitations and undergone major evolutionary changes—most notably the development of the coronary stent. Worldwide, many thousands of patients now safely undergo percutaneous coronary intervention every day, and the numbers continue to grow. In many countries, the numbers are similar to, or exceed, bypass surgical procedures. Although, at first, PTCA was indicated only as treatment for chronic stable angina caused by a discrete lesion in a single vessel, this has now progressed to encompass multi-lesion and multi-vessel disease. Moreover, percutaneous intervention is now becoming widely used in the management of unstable angina and acute myocardial infarction with definite benefits in terms of morbidity and mortality. The effectiveness and safety of these procedures has undoubtedly been enhanced by the adjunctive use of new anti-platelet and antithrombotic agents. As the indications increase and more patients are treated, so inevitably do the demands on healthcare budgets. Undoubtedly, percutaneous intervention is expensive. However, this burden must be weighed against bypass surgery, which is even more costly, and multi-drug treatment—which would be required over many years. Although percutaneous coronary intervention has held centre stage in cardiology, major in-roads have also been made in non- coronary areas. Transcatheter valvuloplasty, ethanol septal ablation and closure devices have become effective and safe alternatives to surgery, as have paediatric interventional procedures. A greater understanding of cardiac electrophysiology has led to important advances in the treatment of arrhythmias, and implantable cardioverter defibrillators are benefiting ever larger numbers of patients. Where are we heading? This is perhaps the biggest question in the minds of many interventional cardiologists. New technology generated by industry and new techniques coupled with high levels of expertise are fuelling advances in almost all areas of interventional cardiology. As drug-eluting stents address the Achilles’ heel of angioplasty and stenting—restenosis—the huge increase in percutaneous coronary procedures seen over recent years is likely to increase even further, and will probably be double the rate of bypass surgery within a decade. In writing and editing this book, I have endeavoured to present broad (and sometimes complex) aspects of interventional cardiology in a clear, concise and balanced manner. To this end, an easy-to-read style of text, avoiding jargon and exhaustive detail, has been used supplemented with many images and graphics. EVER D GRECH Sheffield, July 2003 vii Acknowledgements I have many people to thank for helping me develop and produce this book. I am very grateful to my coauthors who have all willingly contributed their time and expertise. I would also like to recognise the positive efforts and invaluable assistance of the British Medical Journaleditors and illustrators. These include Trish Groves, Mary Banks, Eleanor Lines, Greg Cotton, and Naomi Wilkinson. Finally, my enduring gratitude goes to my family for their unfailing encouragement, patience, and love. viii