Understanding the blood supply to your heart
This heart is a muscular organ kept alive by millions of blood vessels supplying oxygen and nutrients to give it energy to keep pumping. The three main blood vessels that are of utmost importance are the Left Anterior Descending (LAD) artery, the Left Circumflex Artery (LCx) and the Right Coronary Artery (RCA). If the heart doesn’t get enough oxygen, chest pain or a heart attack can result.
Role of the 3 main coronary vessels
Blockages in the heart is due to a pathological process called Atherosclerosis.
Atherosclerosis (sometimes known as hardening or clogging of the arteries) is the process by which cholesterol and fatty deposits (called plaque) narrow the coronary artery, depriving the heart muscles of oxygen and nutrients it needs to function well. Over time, this can weaken or damage the heart. If a plaque splits or breaks, the body tries to fix this by forming a blood clot around it. The new clot can block blood in the artery and stop blood flow to the heart. This is a common cause of a ‘heart attack’.
Risk factors that cause atherosclerosis
Non-modifiable risk factors
Modifiable risk factors
What is a Coronary Angioplasty?
Coronary Angioplasty is a non-surgical procedure done under local anesthesia in a radiological center to open up narrowed coronary arteries to improve blood flow to the heart. This is typically done through a small injection in your wrist (or groin) and achieved using small specialized catheters (tubes) advanced to your heart under X-ray guidance.
This procedure is also known as percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) was first performed by the late Dr Andreas Gruntzig (1939-1985) on March 22nd 1977 on a 38 year old man with severe blockage of the LAD artery who did not want to undergo a bypass surgery. The success of this first angioplasty procedure paved the way for the cutting edge treatments we have to treat coronary artery disease today.
Coronary angioplasty is divided into:
- 1Balloon Angioplasty (also known simply as “ballooning”)
A small balloon at the tip of the catheter is positioned at the blocked or narrowed area of the coronary artery. When the balloon is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow to the heart. This procedure is sometimes complicated by vessel recoil and restenosis (renarrowing) and therefore often followed by placing a coronary stent to stabilize the blocked area and keep it from renarrowing.
- 2Balloon Angioplasty with stenting
In most cases, balloon angioplasty is performed in combination with implantation of a stent. A stent is a small, metal mesh tube that acts as a scaffold to provide support inside the coronary artery.
A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed artery. Once in place, the balloon is inflated and the stent expands to the size of the artery and holds it open. The balloon is deflated and removed, and the stent stays in place permanently. During a period of several months, the artery heals by forming a thin layer of tissue over the stent and the stent gradually becomes part of the blood vessel wall.
Specialized techniques such as rotablation and shock-wave therapy may be used by your interventional cardiologist to treat more complex coronary disease if needed.
Contrary to what many believe, coronary angioplasty does not reduce the blockage by removing the cholesterol and fatty deposits (plaque). Instead, these deposits are displaced to the side by the stent so that normal blood flow may be restored.
Why do I need a Coronary Angioplasty?
1. You have Angina Pectoris
2. Your cardiac test results are abnormal
3. You are suspected of having a heart attack
Is this procedure safe?
In recommending this procedure, your cardiologist has balanced the benefits and risks of the procedure against the benefits and risks of not proceeding. Your doctor believes there is a net benefit to you going ahead. The procedure should only be performed by certified interventional cardiologists.
An Coronary Angioplasty is generally a safe procedure. However, as with any invasive procedure, there are risks and special precautions will be taken to decrease these risks.
The complications from a Coronary Angioplasty include:
Common risks (more than 5%)
Uncommon risks (1-5%)
Rare risks (less than 1%)
- 1a. Development of blood clots in the legs or lungs
- 2b. Stroke or Heart attack
- 3c. Death in extremely rare cases.
Please talk to your cardiologist about any concerns you may have about the risks and benefits of the procedure.
What other options do I have?
The build-up of fatty deposits (plaques) in the arteries of the heart change the once normally smooth and flexible artery to one that is hardened and inflexible (termed atherosclerosis). This is unfortunately not reversible even with dietary modification, supplements and exercise.
The treatment strategy for Coronary artery disease (CAD) is largely dependent on the Severity of Disease at the point of diagnosis. Apart from Coronary angioplasty, the other options include:
- 1Lifestyle modification and medications
- 2Coronary Artery Bypass Surgery (CABG)
The choice of angioplasty or bypass surgery is based on physician and patient preference, as well as patient specific characteristics. In some cases, coronary angioplasty is not the best option and bypass surgery may be advised instead by your cardiologist.
The situations by which CABG may be indicated include:
In a CABG, the surgeon uses a portion of a healthy artery (either the radial artery from the arm or the Internal mammary artery (IMA) from the chest) or vein (saphenous vein from the leg) to create a detour or bypass around the blocked portion of the coronary artery. Depending on the number of arteries blocked, the patient may receive 1 to 5 bypasses.
CABG operations are performed under general anesthesia and during the CABG, a heart lung machine artificially maintains the blood circulation while the heart is stopped and the surgeon operates on the heart. It typically takes 3-5 hours and patients stay 5-7 days stay in the hospital. Hospitalization leave is typically 1 month and it may take up to 3 months to fully recover from the surgery.
How should I prepare for procedure?
Before the day of the procedure
- Any history of peptic ulcer, recent strokes or bleeding tendencies
- Any plans to go for surgery (eg cataract, knee, dental surgery)
- Any history of impaired kidney function
- Metformin (Glucophage) – Stop taking it 2 days before the procedure
- Blood thinners should be stopped 2 days before the procedure at the advise of your doctor. These include:
- 1i. Warfarin (Coumadin; Marevan)
- 2ii. Dabigatran (Pradaxa)
- 3iii. Apixaban (Elequis)
- 4iv. Rivaroxaban (Xarelto)
On the day of the procedure
- ARRIVE PUNCTUALLY — Proceed to the admission office where the staff will settle you comfortably in your room.
- FASTING — You may drink water, consume a light breakfast (eg cereal/eggs/toast/milo) 4 hours before your procedure. Please keep nil by mouth thereafter. Food will be provided for you after the procedure.
- MEDICATIONS — Please consume all your prescribed medications (eg Aspirin and/or Clopidogrel) with plain water on the morning of your procedure except your diabetic drugs (particularly metformin). Bring all your medications with you.
- ATTIRE — Come in casual comfortable attire and bring your toiletries, an extra set of clothes & undergarments as you will be admitted to the hospital after the procedure.
- ALLERGIES — Please inform your doctor if you are allergic to any drugs, contrast dye, latex, tape, local or general anaesthesia (numbing medicines or medicines used to make you sleepy).
Where is the procedure performed?
This test is usually done in the Cardio Vascular Lab (CVL) in the X-ray department (not in the operating theatre).
The following equipment is what you will see in the CVL
How is the procedure performed?
Coronary Angioplasty can be broken down into 3 steps:
- 2Coronary angiogram will be performed
This is a crucial step by which your cardiologist will obtain diagnostic pictures of your heart arteries and identify exactly where the location and severity of the blockages. Based on the findings, a treatment plan will be formulated for you.
This consists of 3 steps:
Advancing the catheter to the coronary arteries
Obtaining Coronary Angiogram pictures
Through this small sheath, catheters will be advanced to the heart under X-ray guidance and contrast will be injected into the coronary arteries.
The location and severity of the blockages will be assessed by your interventional cardiologist and will be discussed with you.
- 3Coronary Angioplasty Procedure
At this point, your interventional cardiologist will discuss the following treatment options for your coronary artery disease management with you :
Coronary Angioplasty if chosen as the option for you comprises of 3 steps.
i. Wiring the artery
ii. Balloon Angioplasty
iii. Implantation of the stent
How will I feel during the procedure?
A 65 year old Man with a past medical history of chronic smoking for 20 pack years, hypertension and hyperlipidemia presented to his GP for chest pain associated with breathlessness. ECG was normal but his CT coronary angiogram showed a significant stenosis in the LAD (left anterior descending) artery. He underwent a Coronary Angioplasty procedure
Step 1 : Performing the Coronary Angiogram
- Vascular Access (through the radial artery)
- Advancing the catheter to the coronary arteries
- Obtaining the Coronary Angiogram pictures
- Picture showing the location of blocked artery
Step 2 : Performing the Coronary Angioplasty
- Wiring the LAD artery
This step sets the stage for balloon catheters and stents to be delivered to the site of narrowing.
- Balloon Angioplasty of the LAD artery
A balloon mounted on a catheter is advanced to the narrowed segment of the artery and when the balloon is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow to the heart
- Stenting of the LAD artery
A stent mounted on a catheter is advanced to the narrowed segment of the artery the balloon within the stent is inflated. The stent expands to the size of the artery and holds it open. The balloon is deflated and removed, and the stent stays in place permanently.
- Final result
This is final result which shows a widely expanded stent, restoring the normal blood flow in this previously critically narrowed artery.
Are there any other procedures done during a Coronary Angioplasty?
Additional tests may be done if more information about your coronary arteries is needed to further optimize the results of your angioplasty.
These tests may include but not limited to :
i. Fractional Flow Reserve (FFR) Study
What happens after the procedure is completed?
- 1General nursing care
- 2Care of the catheter puncture site
- 3Going home
You will be allowed to go home
Recovering At Home
Unless otherwise advised by your cardiologist, you may go back to your normal routine soon after the procedure. As you recover, the following guidelines should be followed:
Diet – A heart healthy diet should be followed as advised by your cardiologist
Fluid intake - Be sure to drink eight to ten glasses of clear fluids (water is best) to flush the contrast material from your system.
Care for the catheter insertion site
If you had a groin (femoral) procedure
If you had a transradial (wrist) procedure
If your wrist bleeds once you are home, do not panic. Follow these steps to control the bleeding:
Taking Care of Your Heart
You have taken a courageous step in going through the angioplasty and it is now time to ensure that it is the last cardiac procedure you will ever need. Your cardiologist has prescribed lifestyle changes and medications to improve your heart health. It is crucial to be committed to a heart-healthy lifestyle and work faithfully with your doctor to halt the process of atherosclerosis so that you can be healthy and active for a long time.
What is a Heart-Healthy Lifestyle?
The key to a healthy heart is not to completely switch to a plant-based diet overnight. The secret is to proactively choose a diet that is balanced and nutritious, one that is high in vitamins, minerals, fibre and other nutrients that helps to control the risk factors that led to the development of heart blockages.
- 1Diet - Consume nutritious food that is good for your heart
- 2Cardiac Rehabilitation
Cardiac rehabilitation is a very important component of your journey towards a strong and healthy heart again.
The components of Cardiac Rehabilitation include:
Many studies has showed repeatedly that moderate intensity exercise on most days of the week and stress reduction have the following benefits :
Starting an exercise program need not always mean hiring a personal trainer to force you to exercise or seeking professional help to reduce stress (eg seeing a psychiatrist).
If you are recovering from a heart attack, please discuss with your doctor when it is safe to start/resume a regular exercise activity.
- 3Medications – take medications as directed
Your cardiologist has put in much thought in prescribing the medications to help your heart work better, relieve your symptoms and reduce the risk of angina, heart attack and heart failure.
The medications usually include:
You may be tempted to stop or reduce the medications after reading about the side effects from the internet, from whats app messages sent to you or from well- intentioned friends and family members. This is to be avoided and you should discuss with your cardiologist during the follow-up appointment before any medications are stopped.
It is potentially life-threatening if you stop medications without consulting your cardiologist especially if you had a balloon angioplasty with stenting. Stents require 2 blood-thinning medications (Aspirin, Clopidogrel or Ticagrelor) to stay healthy.
- 4Cardiovascular risk factor management
There are many risk factors that has accelerated the development of blockages in the arteries of your heart (atherosclerosis) and your cardiovascular risk can be reduced by at least 80% if the following tips are followed:
- 5Follow-up appointments – Do not default on your reviews
When to call the doctor
Call your cardiologist if you have the following symptoms:
Site of Catheter insertion
- History of Angioplasty - https://www.pcronline.com/About-PCR/40-years-angioplasty/Spotlight-on/Experiencing-the-history-of-angioplasty
- Angioplasty vs Bypass surgery for Coronary artery disease - https://www.ahajournals.org/doi/10.1161/01.CIR.0000044747.37349.64
Don't wait for your symptoms to worsen.
Early intervention can save your life.
Heart conditions left unchecked can lead to serious consequences. Seek peace of mind. Seek early intervention.