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Note
1 * ACC defines DTB as the time from first medical contact (FMC) to first establishment of reperfusion with an interventional device; the preferred term is “FMC-to-device time.” FMC is the time of on-scene arrival of emergency medical service, or the time of hospital arrival in case the patient transports himself. First establishment of reperfusion corresponds to the first balloon inflation or thrombectomy that successfully re-establishes coronary flow. Note that the term DTB is not used in ESC guidelines: “STEMI diagnosis-to-wire crossing” is used instead.
3 Stable Ischemic Heart Disease and Approach to Chronic Chest Pain
I. Causes of angina and pathophysiology of coronary flow
IV. Medical therapy: antiplatelet therapy
V. Medical therapy: antianginal therapy and risk factor control
VI. Indications for revascularization
VII. CABG and CABG vs. medical therapy
VIII. PCI and PCI vs medical therapy
IX. PCI vs. CABG in multivessel and left main disease
X. High-surgical-risk patients
XI. Role of complete functional revascularization
XIII. Enhanced external counterpulsation (EECP)
Appendix 1. Notes on various surgical grafts
Appendix 2. Coronary vasospasm (variant angina, Prinzmetal angina)
Appendix 3. Microvascular endothelial dysfunction
Appendix 4. Women with chest pain and normal coronary arteries
Appendix 5. Diagnostic strategy for ischemia with non-obstructed coronary arteries (INOCA)
Appendix 6. Myocardial bridging
Appendix 7. Coronary collaterals, chronic total occlusion
Appendix 8. Hibernation, stunning, ischemic preconditioning
I. Causes of angina and pathophysiology of coronary flow
A. Angina caused by fixed coronary obstruction
Coronary blood flow constitutes ~5% of the total cardiac output and may increase up to 5 times with exercise. Normally, the coronary microcirculatory resistance constitutes the only resistance to myocardial flow; the epicardial vessels are just conductance vessels that offer no resistance to myocardial flow. In the presence of a functionally significant stenosis, classically a 70% diameter stenosis, the trans-stenotic flow drops during exertion; at a 90% diameter stenosis, the trans-stenotic flow drops at rest. During exercise or adenosine infusion, exten- sive microvascular dilatation occurs, requiring an extensive increase in flow to fill the dilated circulation;