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Canadian Journal of Cardiology

Obesity and Coronary Artery Disease: Evaluation and Treatment

Published:December 11, 2014DOI:https://doi.org/10.1016/j.cjca.2014.12.008

      Abstract

      With the increasing prevalence of obesity, clinicians are now facing a growing population of patients with specific features of clinical presentation, diagnostic challenges, and interventional, medical, and surgical management. After briefly discussing the effect of obesity on atherosclerotic burden in this review, we will focus on strategies clinicians might use to ensure better outcomes when performing revascularization in obese and severely obese patients. These patients tend to present comorbidities at a younger age, and their anthropometric features might limit the use of traditional cardiovascular risk stratification approaches for ischemic disease. Alternative techniques have emerged, especially in nuclear medicine. Positron emission tomography-computed tomography might be the diagnostic imaging technique of choice. When revascularization is considered, features associated with obesity must be considered to guide therapeutic strategies. In percutaneous coronary intervention, a radial approach should be favoured, and adequate antiplatelet therapy with new and more potent agents should be initiated. Weight-based anticoagulation should be contemplated if needed, with the use of drug-eluting stents. An “off-pump” approach for coronary artery bypass grafting might be preferable to the use of cardiopulmonary bypass. For patients who undergo bilateral internal thoracic artery grafting, harvesting using skeletonization might prevent deep sternal wound infections. In contrast to percutaneous coronary intervention, lower surgical bleeding has been observed when lean body mass is used for perioperative heparin dose determination.

      Résumé

      Avec l'augmentation de la prévalence de l'obésité, les cliniciens font face à une population croissante de patients présentant des caractéristiques spécifiques en termes de présentation clinique, de défis diagnostiques et thérapeutiques, en ce qui a trait à la prise en charge médicale et aux techniques de revascularisation. Après avoir brièvement discuté des répercussions de l'obésité sur l'athérosclérose, cet article mettra l'accent sur les stratégies que peuvent utiliser les cliniciens pour l’obtention de résultats optimaux concernant les questions de revascularisation chez les patients obèses et sévèrement obèses. Ces patients ont tendance à présenter des comorbidités à un plus jeune âge, et leurs caractéristiques anthropométriques peuvent limiter l'utilisation des approches de la stratification traditionnelle à la recherche d’ischémie myocardique. Des techniques alternatives ont vu le jour en particulier en médecine nucléaire. La tomographie par émission de positron (TEP rubidium) peut s’avérer la technique d'imagerie diagnostique de choix. Une fois la revascularisation considérée, les caractéristiques associées à l'obésité doivent moduler les stratégies thérapeutiques. Lors d’une intervention coronarienne percutanée (ICP), une approche radiale doit être favorisée et les nouveaux agents antiplaquettaires devraient être privilégiés. Lors d’une ICP, une anticoagulation titrée à partir du poids total du patient de concert avec l'utilisation des endoprothèses médicamenteuses est conseillée. Au sujet de la revascularisation chirurgicale, une approche de type « coeur battant » pour la revascularisation par pontage coronarien peut conférer des avantages supplémentaires par rapport à l'utilisation de la circulation extracorporelle. Pour les patients où le chirurgien utilise les deux artères mammaires internes, le prélèvement de l’artère par squelettisation a montré des avantages intéressants pour prévenir les infections de plaie sternale profonde. Un risque de saignement chirurgical plus faible a été observé quand la masse maigre du patient est utilise pour la détermination des doses périopératoires d’héparine.
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