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Rice BIOE 301 - Lecture Notes

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BME 301Review of Last TimeSlide 3Heart AttacksTissue Plasminogen ActivatorThrombolytics DrugsEffectiveness of ThrombolyticsCost-Effectiveness of ThrombolyticsSlide 9How Do We Treat Atherosclerosis?Slide 11Slide 12Slide 13Slide 14PTCA: EffectivenessSlide 16StentsSlide 18Drug Eluting StentsSlide 20Slide 21Slide 22Slide 23CABG ProcedureSlide 25Heart-Lung MachineHeart Lung MachineSlide 28Slide 29CABG EffectivenessInnovationsComparison of RX MethodsSlide 33What Would You Do?Prevention or Treatment?Progression of Heart DiseaseAssignments Due Next TimeBME 301Lecture SeventeenReview of Last TimeBurden of heart diseaseCardiovascular systemHow do heart attacks happen?Diagnosis of Atherosclerosis Blood tests  Electrocardiograms (ECG)  Stress tests  Coronary angiography  Ultrasounds  Computed tomography (CT)Heart Attacks Treatment of Acute Occlusion:Thrombolytics DrugsTissue Plasminogen ActivatorTissue plasminogen.activator (tPA):A thrombolytic.agent (can dissolve blood clots)Approved for use in certain patients having heart attack or strokeClinical Studies:tPA and other.clot-dissolving agents can reduce the amount of damage to the heart muscle and save livesTo be effective, they must be given within a few hours after symptoms beginAdministered through an intravenous (IV) line in the arm by hospital personnelPatients treated within 90 minutes after onset of chest pain are one-seventh as likely to die compared to patients who receive therapy after 90 minutesThrombolytics DrugsRisks of thrombolytics:Intra-cranial hemorrhage Increased risk in those > age 70Patients may require further interventionCosts of thrombolytics:tPA = $2300Streptokinase = $320Effectiveness of ThrombolyticsClinical Trial:In 15 countries and 1081 hospitals41,021 patients with evolving myocardial infarction Randomly assigned to 4 different strategies:Streptokinase and subcutaneous heparinStreptokinase and IV heparinAccelerated tissue plasminogen activator (t-PA) and IV heparinCombo of streptokinase plus t-PA with IV heparinPrimary end point was 30-day mortalityResult: Streptokinase & subcut. heparin: 7.2% (stroke 0.49%)Streptokinase & IV heparin: 7.4% (stroke 0.54%)Accelerated t-PA & IV heparin: 6.3% (stroke 0.72%)Combo of both with IV heparin: 7.0% (stroke 0.94%)Cost-Effectiveness of ThrombolyticsTherapy Patient Group $ per yr life savedtPA Post MI high risk $3,600tPA Acute MI, large infarct, treatment started >2 hours post$24,200CounselingSmoking cessation $1300-$3900CABG Two vessel disease, severe angina$9,200-$42,500http://www.sciencedirect.com/science?_ob=ArticleURL&_aset=B-WA-A-A-A-MsSAYZA-UUA AUYWDCBYZYAUYUBBVZZYBWAUBWEUBAU&_rdoc=1&_fmt=full&_udi=B6T1048NJXK25&_coverDate=5%2F22%2F2003&_cdi=4876&_orig=search&_st=13&_sort=d&view=c&_acct=C000004378&_version 1&_urlVersion=0&_userid=108429&md5=5f493caa5f65762c23c0d90eaea8b92dHeart Attacks Treatment of AtherosclerosisHow Do We Treat Atherosclerosis? AngioplastyPTCA: EffectivenessCannot always successfully perform procedureDiffuse diseaseTotal occlusionCalcified diseaseRestenosisOccurs in 25-54% of patientsUsually occurs within 6 monthsHow Do We Treat Atherosclerosis? StentStentsStentsDrug Eluting Stentshttp://www.npr.org/features/feature.php?wfId=1452217How Do We Treat Atherosclerosis? CABGCABG ProcedurePatient is prepped, general anesthesiaChest access is gained, through sternumGraft vessel is retrievedExpose heart through pericardiumDivert blood through heart lung machineStop heartInsert graftReturn circulation to heartClose incisionHeart-Lung MachineThe heart-lung machine:Consists of a chamber that receives the blood from the bodyBlood is pumped by machine through an oxygenatorOxygenator removes CO2 and adds oxygenPump then pumps this newly oxygenated blood back to the bodyConnected to patient by a series of tubes that the surgical team placesHeart Lung MachineHeart Lung MachineHeart Lung MachineCABG Effectiveness2001: 516,000 CABG procedures performedProcedure takes 4-6 hours, 5-7 day hospital stayGrafts remain open & functioning for 10-15 yrsRisks:Heart attack (5%) Stroke (5%) (risk greatest in those over 70 years old) Death (1-2%) Sternal wound infection (1-4%)“Post-pericardiotomy syndrome“ (30%)Occurs few days to 6 months after surgerySymptoms are fever and chest painSome people report memory loss and loss of mental clarity or "fuzzy thinking" following CABGInnovationsOff-pump CABG:http://www.surgery.usc.edu/divisions/ct/videos-mpeg-offpumpcoronaryarterybypassgrafting.htmlClosed chest CABG:http://www.hsforum.com/stories/storyReader$1537Comparison of RX MethodsHospital Stay:CABG – 4-7 daysAngioplasty – 1-2 daysStent – 1-2 daysRestenosis:CABG – 5-6%, usually after 5 yearsAngioplasty – 25-45%, usually within 6 monthsStent – 15-20%, usually within 6 monthsComparison of RX MethodsCostCABG $35,000Angioplasty $17,000Stent $19,000Cost-effectivenessAdditive procedures:Within 5 years, 20-40% of patients have second PTCA, 25% have CABGAdditive costs:0 years: per patient costs of PTCA 30-50% those of CABG1 year: 50-60%3 years: 60-80%>3 years: >80%Moving Target ProblemWhat Would You Do?AngioplastyStentCABGPrevention or Treatment?http://www.nytimes.com/2004/03/21/health/21HEAR.htmlProgression of Heart DiseaseHigh Blood PressureHigh Cholesterol LevelsAtherosclerosisIschemiaHeart AttackHeart FailureAssignments Due Next Time


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