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Ebook Practical cardiology (2nd edition): Part 2

(BQ) Part 2 book "Practical cardiology" presentation of content: The revascularisation patient, the patient with palpitations, the patient with dyspnoea, the patient with a murmur, other problems. | C H A P T E R  5 THE REVASCULARISATION PATIENT The rather grand term revascularisation refers to the use of coronary angioplasty or surgery to improve myocardial blood supply. Angioplasty Balloon dilatation of coronary artery stenoses was first performed in the late 1970s by Andreas Grunzig. The technique has undergone many refinements and is now widely used for the treatment of angina not responding to medical treatment. Angioplasty has not been shown to improve the prognosis of patients with stable angina. Coronary artery bypass grafting (CABG) has similarly not been shown to prolong life for most stable angina patients. However, both treatments are very successful in relieving the symptoms of angina. The COURAGE Trial compared optimal medical treatment of angina with angioplasty but excluded patients with symptoms refractory to medical treatment.1 Not surprisingly, this group of stable mild angina patients had a similar outcome with angioplasty and medical treatment. The trial suggests that compared with optimal medical treatment, angioplasty is a safe and slightly more effective treatment for stable angina. Patients can make an informed choice between these two treatments. The majority of patients treated with angioplasty in Australia have acute coronary syndromes and here there is good evidence of prognostic benefit with angioplasty compared with medical treatment. In many centres one-, two- and complicated three-vessel disease are managed this way. It has been shown to be as effective as coronary surgery for these patients but at the price of a higher rate of re-intervention. This is because the greatest limitation of angioplasty is the rate of restenosis in vessels that have been dilated. Restenosis Restenosis has been reported in as many as 40% of balloon angioplasties where a coronary stent (p. 199) has not been used—plain old balloon angioplasty (POBA). Re-dilatation is usually possible but a similar risk of restenosis occurs after a second dilatation.