Unstable angina and arterial hypertension

Leszek Kinasz, MDLeszek Kinasz, MD

American Heart of PolandAmerican Heart of Poland

Ustron, PolandUstron, Poland

Clinical data

Female, 59 years oldFemale, 59 years old Unstable angina (CCS class 4)Unstable angina (CCS class 4) Hypertension since 1999, currently required Hypertension since 1999, currently required

4 drugs (ACEI, beta-blocker, duretic, 4 drugs (ACEI, beta-blocker, duretic, calcium channel blocker)calcium channel blocker)

HypercholesterolaemiaHypercholesterolaemia History of pulmonary oedemaHistory of pulmonary oedema BMI 35BMI 35

Clinical data

RR 220/120RR 220/120 HR 64/minHR 64/min Pulmonary congestionPulmonary congestion EKG: ST depression and negative T wave in inferior and EKG: ST depression and negative T wave in inferior and

lateral leadslateral leads UKG: LVEF 55%, hypokinesia of inferior segments, MVI(+)UKG: LVEF 55%, hypokinesia of inferior segments, MVI(+) Lab tests: CPK, CPK-MB, Troponin I - normal, Lab tests: CPK, CPK-MB, Troponin I - normal,

Creatinine 1.4 mg%Creatinine 1.4 mg%

Coronary angiography (CAG)

RCA LAO60:99% lesion in distal segmenttype B2

LCA RAO30, Caud 15Normal epicardial segments

PCI: 7F JR guiding cath, 0,014” BMW wire,

RCA LAO60:predilatation and stent positioning(BX Velocity 3.0x18 mm)

After stenting: max. pressure 18atm

After PCI:

Persisted chest pain and ST/T changes on Persisted chest pain and ST/T changes on the EKG monitorthe EKG monitor

RR 200/120 RR 200/120 -a rigorous treatment of hypertension-a rigorous treatment of hypertension(NTG i.v. and i.a., Furosemid i.v., (NTG i.v. and i.a., Furosemid i.v., nifedipine s.l.) without effect on anginanifedipine s.l.) without effect on angina

What is a cause of the chest pain?

Occlusion of a small AM branch?Occlusion of a small AM branch?

AM

Hypertension?Hypertension?

If so, what should be done next?If so, what should be done next?

1. More intensive pharmacological 1. More intensive pharmacological treatmenttreatment2. Further diagnosis of hypertension2. Further diagnosis of hypertension

What is a cause of the chest pain?

Renal angiography

Right renal artery

Left renal artery

Angio performed in AP view, with Right Judkins catheter used previously for PCI

Renal stenting as a one-stage procedure with PCI:

Renal stenting:Guiding catheter: 7F, Judkins RightWire: 0,014” BMWStent: Corinthian 6.0mm, 14 atm,

Left renal artery after stenting

Diagnostic cath, PCI and Renal Stenting as one-stage procedure: Coronary diagnostic catheters:Coronary diagnostic catheters: 22 No of wires: No of wires: 11 No of guiding catheters:No of guiding catheters: 11 No of balloon catheters:No of balloon catheters: 11 No of stents:No of stents: 22 Contrast: Ultravist Contrast: Ultravist 190 ml190 ml X-Ray expositionX-Ray exposition 10.5 min.10.5 min.

After the procedure

No chest painNo chest pain Arterial pressure: 150/90Arterial pressure: 150/90 Resolution of ST/T changes in serial ECGResolution of ST/T changes in serial ECG Lab tests on the next day:Lab tests on the next day:

-cardiac enzymes in normal range-cardiac enzymes in normal range-serum creatinine 1.2 mg%-serum creatinine 1.2 mg%

Hospital stay:Hospital stay: 36 hours36 hours

Discussion:

Symptoms suggesting renal artery stenosis (RAS)Symptoms suggesting renal artery stenosis (RAS)in the presented patient:in the presented patient:

-short history of hypertension-short history of hypertension-diastolic hypertension resisted to -diastolic hypertension resisted to pharmacological treatmentpharmacological treatment-the history of pulmonary oedema despite of -the history of pulmonary oedema despite of preserved global LVEFpreserved global LVEF

CAD & RAS In 15% of patients undergoing CAG, a significant In 15% of patients undergoing CAG, a significant

RAS (>50%) can be foundRAS (>50%) can be found

No of narrowed No of narrowed RiskRiskcoronary arteriescoronary arteries of RASof RAS00 8.8%8.8%11 10.7%10.7%22 17.6%17.6%33 29,9%29,9%LMLM 39.0%39.0%

(The Duke University Experience)

RAS & Risk of MACE

AMIAMI

RevascularizationRevascularization(PTCA or CABG)(PTCA or CABG)

No-RASNo-RASRASRAS pp

13.8%13.8% 41%41% 0.010.01

33.1%33.1% 58.3%58.3% 0.010.01

(The Duke University Experience)

The influence of renal stenting on UA and CHF

N=48 pts N=48 pts with UA or CHF and concomitant with UA or CHF and concomitant

uni- or bilateral RASuni- or bilateral RAS

Results:Results:After renal stenting resolution of symptoms in 88% After renal stenting resolution of symptoms in 88%

of patients during 8.4 months follow-up.of patients during 8.4 months follow-up.

Am J Cardiol 1997;80:363-6

Influence of renal stenting on renal function

Circulation 1998;98:642-7

0

0,5

1

1,5

2

2,5

0 6 12 24 36 48

Creatinine

months

Conclusions:

Patients with angina and the history suggesting Patients with angina and the history suggesting RAS, coronary angiography should be always RAS, coronary angiography should be always followed by renal artery angiography.followed by renal artery angiography.

Renal artery angiography and renal stenting can be Renal artery angiography and renal stenting can be performed easily during CAG or PCI as a one performed easily during CAG or PCI as a one stage procedure at the low risk and low additional stage procedure at the low risk and low additional cost.cost.