Know your options for treating heart disease

With the explosion of technological advances and research-based knowledge in the treatment of coronary disease, it is not as easy as you might think to stay abreast of the latest developments. Familiarizing yourself ahead of time with all the options now available will help you make an informed decision in the event that you or someone close to you is diagnosed with coronary disease.

Coronary artery disease occurs when a buildup of atherosclerotic plaque narrows or blocks any of the arteries that nourish the heart muscles. The buildup reduces the amount of blood feeding the heart. This can lead to chest pain (angina), shortness of breath and other symptoms, and can set the stage for a myocardial infarction (heart attack) in which blood flow to a portion of the heart is completely blocked, threatening that area of cardiac muscle with cell damage and death.

There are three general categories of treatment for coronary artery disease: medical therapy, catheter-based procedures (formerly just balloon angioplasty) and bypass surgery. All have the same goal: fix the problem so there is a healthy supply of blood to the heart.

How your doctor chooses to do this will depend on many factors, including the extent of the disease, the number of blood vessels affected and the severity of obstructions. In addition, he or she must consider your age, past medical history and any other health problems you may have.

Patients considered to be at low riskleft are usually given medications rather than invasive procedures to slow or stop the disease’s progress. Medical therapy may include drugs to alleviate angina by dilating the blood vessels or decreasing the heart’s need for oxygen during physical activity.

Aspirin may be given to prevent blood from clotting and occluding blood flow.

Lipid-lowering drugs may be prescribed to reduce cholesterol levels and prevent further buildup of plaques.

Beta-blockers help the heart beat slowly and less forcefully, reducing the oxygen requirements of the heart muscle.

Calcium-channel blockers help keep arteries relaxed by keeping tiny pores (the "calcium channels") closed. Normally, calcium ions would enter the arteries through these channels, regulating the flow of blood by causing the artery to contract.

Nitrate medications relax blood vessels all over the body so that the heart doesn’t have to work as hard.

Angiotensin converting enzyme (ACE) inhibitors may also benefit heart attack patients by preventing future coronary events, according to recent research.

Anyone with coronary disease should follow a heart-healthy lifestyle that includes regular exercise, a low-fat diet and abstaining from smoking.

Catheter-Based Treatments

Balloon angioplasty and other catheter-based interventions are ideal for many patients with isolated blockages in one or two coronary arteries. These procedures use slim, flexible tubes (catheters) to snake into the coronary arteries and remove or push aside plaques. They are called "percutaneous coronary interventions," or PCIs.

In angioplasty, an uninflated balloon is inserted into an artery, often in the groin, and guided to the blocked area of the heart. The balloon is then inflated, compressing the plaque against the artery wall, widening the channel for blood flow. In many cases, a stent – a tiny mesh tube – is then inserted in the artery to help keep it open.

Other catheter procedures are used, but not as frequently as angioplasty and stenting. The cardiologist decides which technique to use based on the composition and location of the blockages. Other PCIs include:

Rotational atherectomy, which involves sanding away plaque with a high-speed, rotating drill-like catheter tip;

Transluminal extraction, which breaks off bits of plaque and suctions them out through a tube; and

Direct coronary atherectomy, in which a cutting blade shaves off slices of plaque and captures them in a chamber.

Some medical centers are employing laser catheters to vaporize plaque. There are those, however, who feel that the risk of damage to the artery wall may be too great with currently available laser systems.

PCIs offer the distinct advantage of a fast recovery. Patients usually stay in the hospital overnight and can return to normal activity in a couple of days. However, while PCIs are easy to undergo, the rate of reblockage or restenosis is high. About 15-30 percent of all patients require a second angioplasty or a bypass surgery within six months. Therefore, today, most PCI patients have a stent inserted. The rate of restenosis in stented arteries is 10-20 percent. A large number of clinical trials are underway to see whether administering certain medications – or combinations of medications – before, during and after PCI can further reduce the restenosis rate.

Who Needs Bypass Surgery?

Bypass surgery is usually recommended when there is atherosclerosis in more than two vessels, or in the left main trunk artery, endangering blood flow to a large portion of the heart muscle. In these cases, any interruption to blood flow could be fatal.

During a conventional bypass, the patient’s heart is stopped and a heart-lung machine takes over breathing and blood circulation. The breastbone is separated vertically and the ribs moved aside to expose the entire heart. The surgeon removes one or more arteries or veins from other parts of the body to use as bypass grafts to reroute blood around the blocked area. Among the options: the internal mammary (also called internal thoracic) artery from the chest, the saphenous vein from the leg and the radial artery from the forearm.

Bypass surgery has been proven very effective and safe. The mortality rate for the surgery now averages one to two percent. Reblockage is not as great a problem as with PCIs. In fact, leg veins are known to stay open or "patent," for five to 10 years, and artery grafts, indefinitely. But despite the operation’s successful track record, the postoperative discomfort and a lengthy (six weeks or more) recovery period mean that this surgery poses a major interruption to everyday life.

Because bypass surgery using the mammary artery is the best way to restore blood flow for the longest period of time, some patients who could get by with a PCI may choose to have a bypass instead. However, patients with other serious medical problems, as well as those considered too frail to withstand major surgery, may be better off having a catheter procedure.

A select few patients qualify for "minimally invasive" bypass surgery. In these cases, the surgeon doesn’t cut through the breastbone but uses a much smaller incision to access the heart. Recovery time is therefore quicker, but the procedure is technically harder for the surgeon, since only a small portion of the heart is exposed to view and tiny instruments must be used to operate through the smaller opening. Minimally invasive techniques can only be performed on patients undergoing bypass surgery for the first time and who have a blocked artery located on the front of the heart.

Some medical centers in more advanced countries of the world are using a new method called "off-pump" bypass, in which the heart-lung machine is not used. This type of surgery may help prevent complications thought to stem from the heart-lung machine, including postoperative confusion and other cognitive problems. Patients with additional health problems who may have been told they are not candidates for a conventional bypass can sometimes undergo an off-pump procedure.

So How Do You Choose?

It’s often hard to say whether two treatment choices offer equal risk. Nothing is black and white. That’s when the physician’s experience becomes invaluable. At such times, patients should not be making a decision alone. The cardiologist’s and the cardiac surgeon’s job should be to give advice based on their experiences and knowledge. This is one situation where it may not be proper for a doctor to just describe the procedures and tell the patient to make a decision. It is also dangerous for a patient to insist on a procedure that may be totally inappropriate in his or her individual circumstances.

Wise patients take time to learn the expected outcome of each treatment, as well as the credentials and experience of the doctors who would perform them. Your doctor should give you a clear description of whatever procedure he or she recommends, tell you why it is recommended and explain the risks and benefits. If you do not feel comfortable proceeding, get another opinion.

Be sure the procedure will be performed at a major medical center with an excellent reputation for cardiac care. Avoid having a PCI at a facility that does not offer a full range of treatments for coronary disease. Such centers may lack backup for unexpected complications.

After weighing these factors, the best option may become obvious. In any case, an informed decision can increase the chances of success and prevent complications down the road. Hope this article has provided you the information you need so that along with your doctor, you will be able to choose the option that’s best suited for you or someone close to you, when the time comes to make that critical decision.