Coronary bifurcation lesions

 Coronary arteries are the vessels which supply blood (oxygen and nutrients) to the heart; this supply may be disrupted due to buildup of cholesterol and fatty deposits, called plaques, on the inner walls of the arteries (atherosclerosis) causing narrowing of the vessel lumen.

A bifurcation lesion is the stenosis or abnormal narrowing of greater than 50% that occurs in a coronary artery at the origin of the side branch or adjacent to the origin of the side branch. It is a difficult to treat lesion.

Signs and symptoms:

Most of the complex lesions have similar sign and symptoms which are as follows:

  • Acute angina pectoris syndrome (set of sign and symptoms due to decreased blood supply to coronary arteries which leads to malfunction or complete damage of the heart muscle)
  • Chest pain, usually left sided, radiating to the neck, jaw or left shoulder of the arm
  • Shortness of breath
  • Palpitations
  • Weakness
  • Lightheadedness
  • Nausea or vomiting
  • Sweating
  • Anxiety
  • Indigestion

Causes and risk factors:

The causes and risk factors involved are like those evident in most of the coronary artery disease, which are as follows:

  • Family history of heart disease
  • Kawasaki disease commonly found in children under 5 years of age
  • Obesity
  • Diabetes
  • Hypertension
  • Age
  • Smoking
  • Hyperlipidemia (elevated levels of lipids in the plasma)

Diagnosis:

Laboratory studies:

There is no specific lab test to diagnose a bifurcation lesion but if the lesion has resulted in acute coronary syndrome there could be an elevation in the white blood cell count. Cardiac specific biomarkers (troponin T and troponin I) will be elevated 4 to 8 hours after the injury which reach its peak in about 12 to 24 hours.

Electrocardiography (ECG):

It is performed to investigate the electrical activity of the heart and to detect any abnormality in its functioning. There are variable findings in the ECG depending on the clinical scenario.

Stress testing:

Exercise ECG is the procedure of choice for the patients who are stable and when their diagnosis is unclear. In individuals who can’t exercise, pharmacologic stress test (with adenosine or dobutamine) may be suggested.

Coronary angiography:

It is the most standard method used for diagnosing coronary lesions wherein a special dye and x-rays shows the blood flow in the arteries of heart and in this case it enables to determine the extent of stenosis (abnormal narrowing) of the coronary arteries. Thus, enabling the evaluation of the further treatment with medical therapy or stent procedure.

Cardiac catheterization:

In this procedure, a catheter is guided through an artery in the arm or leg and eventually into the coronary arteries, simultaneously a high-speed x-ray records the course of the injected dye which flows through the arteries enabling the detection of any blockages.

Prevention:

These lesions usually develop gradually over a period and thus it is possible to prevent it. Prevention can be accomplished by controlling or avoiding the risk factors involved in coronary artery lesions disease and is possible by adopting proper lifestyle modifications and diet which are as follows:

  • Maintain healthy weight by following proper diet and exercise.
  • Avoid smoking.
  • Manage stress.
  • Keep a check on blood pressure and sugar levels.
  • Go for regular health checkups if diagnosed with previous heart problems or having a family history of heart diseases.

Treatment:

Complex coronary lesions cause higher mortality rate than the non-complex lesions. Hence it is essential to treat it immediately and appropriately. However, the medical interventions carry their own risk of associated complications, and it must be managed by proper patient care and education.
Based on the coronary angiography or cardiac catheterization, the following treatment options can be recommended:

Percutaneous coronary intervention: It involves cardiac catheterization, insertion of a stent (usually a metallic tube) which helps to clear the blockage in the artery. Sometimes, two stents may be placed simultaneously. DES (drug eluting stents) are highly recommended than BMS (bare metal stents) as it prevents restenosis.

Medications: The prescribed medications are given in the event of detecting a stenosis which don’t require the use of stents and can be resolved by the drugs alone to clear up the blockage in the coronary artery.

When to seek an immediate medical attention?

The first possible presentation of complex coronary lesions is acute coronary syndrome (unstable angina) which can be detected by the following characteristic features:

  • Chest pain occurs at rest or sleep or with minimal exercise
  • Sudden onset of chest pain that lasts longer than usual
  • When medicines and rest don’t provide relieve from the chest pain

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