Coronary Artery Disease - DrCRaghu

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Coronary arteries are the blood vessels that delivers oxygenated blood to the heart muscle. But, sometimes these blood vessels may get narrowed or blocked due to accumulation of plaque. To open the blockage and restore the function of the arteries, coronary angioplasty is done.

coronary angioplasty involves the temporary insertion of a tiny balloon inside the artery to open the blockage. It is usually combined with the placement of a stent (a metal mesh tube) to widen the artery and prevent the further chance of narrowing.

Why is coronary angioplasty done?

Coronary angioplasty is done to treat narrowing or blockage of the blood vessels:

  • during or after a heart attack.
  • that may result in poor heart function.
  • that reduce blood flow and may result in angina.

Sometimes, it also used as a treatment option when medication and lifestyle modifications fail to improve the heart health.

Risks of coronary angioplasty

Usually, it is a safe procedure, but like all other procedures, it also carries certain risks like:

  • Bleeding at the incision site
  • Infection at the site of the catheter
  • Allergic reactions
  • Blood clots
  • Stroke
  • Heart attack
  • Kidney damage
  • Bleeding in the abdomen

What happens before the procedure?

A physical examination and blood test are done to evaluate the overall health condition. The person needs to follow the below-given instructions before undergoing the procedure:

1. Tell the doctor about:

  • Any allergies
  • The use of current medicines, including vitamin and mineral supplements
  • Any blood disorder
  • Any surgery you may had
  • The past and present medical condition

2. Medicines:

Tell the doctor if you are using blood thinners or any anti-diabetic medicines. The doctor will either advise you to stop or change the dose of the medication.

3. Food and fluid restrictions:

  • Avoid heavy meals, such as meat, fried or fatty foods eight hours before the procedure. Take light foods such as toast and cereal.
  • Fast for six hours before the procedure.
  • Stay hydrated, drink plenty of fluid up to two hours before the procedure.

In most of the cases, you will be discharged on the same day of the hospital, so ask someone to accompany you to the hospital.

 

What happens during the procedure?

The anesthesiologist will administer local anaesthesia to numb the area where the catheter would be placed. Mostly, a catheter is inserted through the groin area, and sometimes through the elbow, or the wrist. Now, by using fluoroscopy (a type of X-ray), the catheter will be guided to the blocked artery. After the catheter reaches the heart, the contrast dye will be injected to make the blockage visible clearly on the X-ray.

Once the catheter reaches the blockage, a tiny balloon is inflated to widen the artery. The expansion will crush the plaques into the wall of the blood vessel and improve the blood flow. Once the blood flow is improved, the catheter will be removed, and a stent would be placed to prevent the risk of further blockage. Finally, the incision will be closed and covered with a sterilized bandage.

 

What to expect after the procedure?

The nurse will check the vitals of the patient. Depending on the condition, the doctor would advise you the hospital stay. You will be advised not to bend or cross the leg for a few days if the procedure is performed through the groin region. Additionally, some other tests like X-rays and an electrocardiogram (ECG) would be done to check the condition. Before discharge, the doctor will give you certain instructions regarding wound care, medications, and lifestyle.

 

Recovery after coronary angioplasty

Recover quickly and keep your heart healthy by following these tips:

  • Quit smoking.
  • Limit the intake of alcohol.
  • Take the prescribed medicines.
  • Check the cholesterol levels regularly.
  • Maintain a healthy body weight.
  • Have a healthy and well-balanced diet.
  • Exercise regularly.

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Coronary artery disease (CAD) is the most common type of heart disease, in which the coronary arteries (major artery that supplies blood to the heart muscle) become rigid and narrowed due to buildup of plaque (deposition of cholesterol) in the inner walls of the heart. This restricts the flow of oxygen rich blood to the heart muscle, which may result in angina (chest pain) and shortness of breath. If the plaque ruptures or due to a complete blockage in the artery, it may result in heart attack or sudden cardiac death.

Causes:

The cause of coronary artery disease is the buildup of plaque in the inner walls of coronary artery, which is called as atherosclerosis.

The plaque makes the inner walls of the artery sticky, so that the inflammatory cells, lipoproteins, and calcium travelling through the blood stream may adhere to the plaque. The plaque gradually enlarges, narrowing the blood vessel and further restricting the blood flow to the heart muscle and reducing the supply of oxygen and nutrients to the heart.

Signs and symptoms:

  • Angina (chest pain)
  • Shortness of breath
  • Palpitations (irregular heartbeats or skipped beats)
  • Tachycardia (fast heartbeat)
  • Weakness or dizziness
  • Nausea
  • Sweating
  • Fatigue, mainly after exercise or any activity.


Risk factors:

  • Age: Risk for damaged or narrowed arteries increases with age.
  • Gender: Men are at greater risk of developing CAD. In women, risk increases after menopause stage.
  • Family history: Risk increases if any family member has coronary artery disease.
  • Smoking: People who have the habit of smoking and who are exposed to smoke are at increased risk of CAD.
  • High blood pressure: It results in the narrowing and hardening of the walls of arteries.
  • High blood cholesterol levels: It can increase the risk of atherosclerosis.
  • Diabetes: It is associated with the symptoms of CAD, such as high BP and obesity.
  • Obesity: Overweight increases the risk of CAD.
  • Life style activities: Reduced physical activity, high stress and unhealthy diet also contribute to the development of CAD.

Other possible risk factors, according to research, include:

  • Sleep apnea: It is a condition in which the person may experience intermittent cessation of breathing during sleep, resulting in reduced oxygen levels in the blood. Sleep apnea may cause an increase in the blood pressure and high strain on the heart, leading to CAD.
  • Increased C-reactive protein (CRP) levels in blood: CRP levels are increased mostly if there is any inflammation in the body. It is a risk factor for CAD.
  • High triglycerides (a type of lipid).
  • High homocysteine (amino acid) levels.
  • Preeclampsia (high blood pressure during pregnancy).
  • Alcohol use can lead to heart muscle damage.
  • Autoimmune diseases such as rheumatoid arthritis and lupus.


Complications:

If left untreated, CAD can lead to life threatening complications such as:

  • Angina: Due to narrowed blood vessels, the heart muscles receive inadequate oxygen laden blood, causing chest pain or shortness of breath.
  • Heart attack: The plaque may rupture forming a clot and blocking the blood flow to the heart muscle.
  • Heart failure: Due to reduced oxygen and nutrient rich blood flow, the heart is unable to pump enough blood, thus increasing its workload. Over time, it may lead to heart failure.
  • Arrhythmia: Reduced amount of blood supply may lead to abnormal heart rhythms.


Diagnosis:

The diagnostic work up includes a physical examination, in addition to medical history, family history, risk factors and any signs and symptoms of CAD. Further diagnostic tests may be recommended:

  • Electrocardiogram (ECG): It records the heart’s electrical activity and helps to determine the blood flow in the heart as well as heart muscle stress.
  • Echocardiogram: It uses sound waves to produce clear images of the heart and helps to identify the damaged heart muscles.
  • Stress test: The test involves performing any high intensity activity like treadmill or bicycling under medical supervision, and close monitoring of heart function during the physical activity, to determine if there are any symptoms of CAD.
  • Cardiac catheterization and angiogram: A special dye is inserted into the coronary blood vessels using a thin, flexible tube called catheter, which is inserted through a small incision at the groin or an arm to view the blood flow in the heart.
  • Heart scan: Computerized tomography (CT) technologies are used to identify the calcium deposits in the blood vessel of the heart, which indicates CAD.


Treatment:


Lifestyle changes:

  • Quit smoking.
  • Avoid processed foods and eat high protein and fiber rich diet.
  • Exercise regularly and lose excess weight.
  • Manage stress.
  • Control diabetes.


Medications:

The doctor may prescribe medications, which help in reducing the symptoms of CAD, such as:

  • Dyslipidemic agents such as statins, niacin, fibrates and bile acid sequestrants a to lower the blood cholesterol levels
  • Aspirin, a blood thinner, to prevent blood clots, which might obstruct the coronary arteries
  • Beta blockers decrease the heart rate and blood pressure and reduce the oxygen demand of the heart.
  • Calcium channel blockers to lower blood pressure
  • Ranolazine, an anti-anginal drug, to reduce chest pain
  • Nitroglycerin to dilate the coronary arteries and reduce chest pain
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) to decrease blood pressure


Surgical procedures:

  • Angioplasty and stent placement: It is also called as percutaneous coronary revascularization, and involves inserting a thin, flexible tube (catheter) into the narrowed coronary artery, followed by a wire with deflated balloon to the narrowed area. The balloon is inflated to widen the blood vessel; a stent may also be placed to keep the artery patent.
  • Coronary artery bypass surgery: A graft is created using any blood vessel in the body, to bypass the blocked coronary arteries.


Prevention:

To maintain healthy arteries and to prevent coronary artery disease, some measures need to be taken such as lifestyle modifications which includes avoiding smoking and alcohol use, exercising regularly to maintain healthy weight, controlling sugar and cholesterol levels in blood and also eating a healthy diet.

 



The tests that are recommended for a patient depends upon what the doctor thinks that the patient has. Before sending you for testing, your doctor would take your detailed health history and examine your body thoroughly. Based on the suspicion, your doctor may refer to one or more tests.

Investigations not only help to detect a disease, they also help to check for presence of possible disease complications and to find out how is the treatment affecting your health.

Blood tests:

  1. Complete blood count (CBC): A complete blood count helps to detect infection, anaemia and other blood disorders. Anaemia is a common finding in heart failure, plus it also contributes to worsening of heart failure. A low platelet count may be caused by medications such as diuretics or heparin.
  2. Cardiac troponins (cTn1, cTnT, high sensitivity troponins): It is an important biomarker present in the blood which is very useful for the detection and prognosis of acute myocardial infarction. Cardiac troponins may also be high in other heart related conditions like acute myocarditis, coronary vasospasm and non-cardiac conditions (e.g. sepsis, chronic kidney disease).
  3. Electrolytes, urea and creatinine: Levels of these help to find out your kidney function. Abnormal levels of electrolytes like potassium can increase the risk of arrhythmias Low levels of sodium is very common in heart failure. High levels of urea and creatinine indicate kidney failure which could be a possible complication of heart disease or its medications.
  4. Liver function tests: Certain drugs such as statins and amiodarone, which are commonly prescribed for patient with heart disease, can trigger liver failure. Liver failure could also be a consequence of heart failure.
  5. Thyroid function test: Medication for heart disease like amiodarone may cause hyper or hypo thyroidism. Altered thyroid hormone can also cause heart dysfunction.
  6. Brain Natriuretic Peptides (BNP or N-terminal pro BNP): BNP is a useful tool to differentiate between cardiac and non-cardiac causes of shortness of breath especially when echocardiography is not available. High levels of BNP and N terminal pro BNP is associated with increased severity of heart disease and greater risk of hospitalisation.

Electrocardiography(ECG):

This test detects and records the electrical activity of the heart. This is a simple, non-invasive test which is very useful to determine abnormalities in the heart rate, rhythm and to identify risk of damaged heart muscle or other structural changes in the heart. This test detects the presence of arrhythmias and coronary artery disease.

Exercise stress testing:

Exercise makes your heart work harder. Exercise stress testing is done either on a treadmill or cycle ergometry with the patient connected to an ECG. Exercise stress testing may identify myocardial ischaemia, haemodynamic/ electrical instability, or other exertion-related signs or symptoms. When an individual is not able to exercise, medications are given to stress the heart and the response is evaluated.

Chest X-ray:

Chest X ray is very useful to differentiate whether shortness of breath is due to a respiratory disease or heart disease. It can also help in detecting complications of heart failure

such as cardiomegaly, interstitial oedema, pulmonary oedema and pleural effusions.

Coronary angiography:

Coronary angiography is useful to determine the health of the coronary arteries. In this test, a catheter is inserted into the coronary arteries and a dye is injected to produce clear X ray images of the coronary arteries. This helps to find out the presence, location and extent of vessel narrowing. The results also help to decide what type of treatment would be most appropriate.

Echocardiography:

This test gives an ultrasound image of the heart. Echocardiography can provide information about the size and shape of heart chambers, blood flow velocities, heart muscle function when they contract and relax, abnormalities of the movement of the heart wall, valve function, and presence of thrombus (blood clot) in the heart.

Stress echocardiography helps in detecting decreased blood flow to heart during exertion. In this test, echocardiography is done immediately post stress. The stress can be exercise or induced by medications.

Myocardial perfusion scanning (MPS):

MPS is a non-invasive test which helps to determine how well blood flows through your heart muscles. In this test, a small amount of a radioactive substance is injected into the blood. The test evaluates the severity of coronary artery disease and provides guidance regarding the need for invasive procedures like angiography or coronary artery revascularisation.

Cardiac Computerised Tomography (CT):

Cardiac CT provides detailed images of the heart. This helps to identify structural abnormalities in the heart and blood vessels such as aneurysms, valve dysfunction and damage to the pulmonary vasculature. Cardiac CT also provides information about patency of grafts following coronary artery bypass graft.

Cardiac Magnetic Resonance Imaging (MRI):

Cardiac MRI uses strong magnetic fields and radiofrequency to provide detailed 3D images of the heart and surrounding structures. The image provides accurate information about cardiac volumes, muscle mass, contractility, and how efficiently the heart is pumping. Like cardiac CT, cardiac MRI also helps to provide information about patency of grafts following coronary artery bypass graft.












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