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

  • The LAD – supplies the front and left hand side of the heart
  • The LCX – supplies the left and sometimes the back of the heart
  • The RCA – supplies the right and bottom side of the heart

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

  • Ageing
  • Menopause
  • Family history of coronary artery disease

Modifiable risk factors

  • Diabetes Mellitus
  • Hypertension
  • Hyperlipidemia
  • Cigarette smoking
  • Diet high in Cholesterol
  • Stressful lifestyle

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:

  1. 1
    Balloon 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.

  1. 2
    Balloon 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%)

  • Minor bleeding or infection at the puncture site
  • Abnormal heartbeat lasting several seconds which settles by itself

Uncommon risks (1-5%)

  • Unable to get the catheter into the leg vein - the procedure may be changed to the opposite leg
  • Abnormal heart rhythm that continues for a long time - this may need an electric shock to correct
  • The femoral artery (in the groin) is accidentally punctured - this usually just requires pressure on the artery
  • Damage to the blood vessels where the catheter travelled to get to the heart

Rare risks (less than 1%)

  • Damage to the heart muscle or valves
  • Damage to your heart's electrical system, which could worsen your arrhythmia and require a pacemaker to correct
  1. 1
    a. Development of blood clots in the legs or lungs
  2. 2
    b. Stroke or Heart attack
  3. 3
    c. 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:

  1. 1
    Lifestyle modification and medications
  • This forms the foundation of all treatment strategies for CAD and work to prevent the continuing build-up of plaque, reduce the symptoms of angina and has been proven to reduce the risk of death by reducing heart attack and heart failure.
  • Medications to reduce the risk of death include aspirin, beta-blockers (eg atenolol, bisoprolol, carvedilol)  and angiotensin-converting enzyme inhibitors (lisinopril, perindopril, enalapril).
  • Medications that reduce the symptoms of angina include beta-blockers, nitroglycerin and calcium channel blockers (amlodipine, nifedipine, diltiazem and verapamil)
  • In some patients, the narrowing of the artery is so great that the lack of blood flow starves the heart muscle of oxygen. Patient will continue to have symptoms of angina despite lifestyle modifications and optimal medical therapy. Restoration of the normal blood flow will thus need to be achieved by coronary angioplasty or CABG.

  1. 2
    Coronary 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:

  • Severe left main (widow-maker) artery stenosis
  • Severe double or triple vessel disease in patients with diabetes and/or heart failure
  • Coronary blockages not suitable for angioplasty (eg completely blocked arteries and severely calcified vessels)

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

  • Your cardiologist will explain how the procedure is performed, the risks and benefits and expected duration of stay in the hospital
  • Informed consent will be obtained
  • Routine blood tests and ECG will be done before the procedure.
  • Inform the doctor of:
  • Any allergies (particularly allergies to iodine, X-ray contrast medium, latex, rubber, plaster and any pain-relieving medications)
  1. Any history of peptic ulcer, recent strokes or bleeding tendencies
  2. Any plans to go for surgery (eg cataract, knee, dental surgery)
  3. Any history of impaired kidney function
  • Instructions for medications
  1. Metformin (Glucophage) – Stop taking it 2 days before the procedure
  2. Blood thinners should be stopped 2 days before the procedure at the advise of your doctor. These include:
  1. 1
    i.  Warfarin (Coumadin; Marevan)
  2. 2
    ii.  Dabigatran (Pradaxa)
  3. 3
    iii. Apixaban (Elequis) 
  4. 4
    iv. Rivaroxaban (Xarelto)
  • Continue Aspirin and/or Clopidogrel if prescribed by your doctor
  • Keep yourself well-hydrated. This will reduce the risk of kidney impairment due to the injection of the dye.
  • Arrange for an adult family member or friend to be with you while waiting for the procedure.

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

  • X-ray Equipment – sends pictures to be viewed on monitors
  • Video monitors – show the X-ray pictures, which are used to guide catheters to your heart
  • ECG monitor – continuously monitors your heart rhythm

How is the procedure performed?

Coronary Angioplasty can be broken down into 3 steps:

  1. 1
    Preparation
  • You will change into a hospital gown and asked to empty your bladder before the procedure so as to minimize any urinary urgency in event the procedure is prolonged.
  • A small intravenous (IV) cannula will be inserted to the left hand to facilitate any administration of IV fluids and medications.
  • You will be brought down to the Cardio Vascular Lab (CVL) where your interventional cardiologist together with a specialized team of cardiac technologists, radiographers and nurses will be on standby to do the procedure.
  • You will lie on a movable X-ray table equipped with X-ray cameras and heart monitors.
  • Three electrodes (small flat sticky patches) will be placed on your chest wall and attached to an ECG monitor that charts your heart’s electrical activity during the test. A blood pressure cuff will also be worn on your left arm to measure. your blood pressure throughout the procedure.
  • A mild sedative will be given by your cardiologist and this will make you sleepy and relaxed but arousable.
  • You will be covered with a sterile drape and a nurse will clean your right wrist with a cool antiseptic solution.
  1. 2
    Coronary 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:

  • Obtaining vascular access
  • A local anaesthetic is injected into the skin of your wrist (or groin), causing a temporary stinging sensation. Once the site is numb, a small 2-3mm plastic sheath will be inserted into the radial (or femoral) artery
  • This step typically takes 10-15mins

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.

  1. 3
    Coronary Angioplasty Procedure

At this point, your interventional cardiologist will discuss the following treatment options for your coronary artery disease management with you :

  • Medical therapy (Healthy lifestyle modification and medications) or
  • Coronary Angioplasty or
  • Coronary Artery Bypass Grafting (CABG)

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?

  • You may feel transient chest tightness as the balloon angioplasty is performed. This is common and to be expected.
  • Please tell your cardiologist about any symptoms you feel during the procedure.
  • This procedure typically takes 30 mins to an hour for an uncomplicated case.

Case example

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

  1. Vascular Access (through the radial artery)
  1. Advancing the catheter to the coronary arteries
  1. Obtaining the Coronary Angiogram pictures
  1. Picture showing the location of blocked artery

Step 2 : Performing the Coronary Angioplasty

  1. Wiring the LAD artery

This step sets the stage for balloon catheters and stents to be delivered to the site of narrowing.

  1. 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

  1. 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.

  1. 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?

  1. 1
    General nursing care
  • You will be brought back to the high dependency ward or general ward for monitoring overnight.
  • Your pulse and blood pressure will be checked often.
  • You will be able to have your meal with your medications and go to the toilet independently if your cardiologist allows.
  • You are encouraged to drink plenty of clear fluids to help clear the X-ray contrast (‘dye’) from your body.
  1. 2
    Care of the catheter puncture site
  • The sheath in your wrist will be removed with a special closure device tightly compressing the site of puncture.
  • Once the puncture site over your wrist is stable with no bleeding, the closure device will be removed and a light pressure dressing will be applied.
  1. 3
    Going home

You will be allowed to go home

  • If your catheter puncture site is not bleeding
  • If you do not have any cardiac symptoms like chest pain or breathlessness
  • If you pulse and blood pressure are normal
  • Once your cardiologist gives the green light to be discharged
  • It is recommended that you have someone drive you home after the procedure to rest

 Medications

  • Please review your medications with your doctor before you go home
  • Ask your doctor if you should continue taking the medications you were taking before the procedure
  • Ask your doctor if you have any questions about this medication
  • Do not stop taking this medication without talking to your cardiologist

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.

Activity guidelines

  • Your doctor will tell you when you can get back to your normal routine. You will need to take it easy for the first two days after you are home
  • Take walks around your house and plan to rest during the day
  • Avoid lifting heavy loads and strenuous activities like running
  • Talk to your doctor about when you can resume sex
  • Discuss with your doctor about a plan for getting regular exercise
  • If you are recovering from a heart attack, discuss with your doctor when it is safe to start/resume a regular exercise activity

Driving

  • You may resume driving once the catheter insertion site recovers
  • Driving is prohibited for 1 month after a heart attack

Medications

  • Take your medications as directed by your cardiologist. This is crucial to the success of your procedure
  • These medications include blood thinners (Aspirin, Plavix or Brilinta) which must never be stopped before consulting with your cardiologist

Care for the catheter insertion site

If you had a groin (femoral) procedure

  • Do not strain during bowel movements for 3 to 4 days after the procedure. This helps to prevent bleeding from the catheter insertion site
  • Do not lift anything that weighs more than 5kg or push or pull heavy objects for the first 5 to 7 days after the procedure
  • Do not do anything strenuous for 5 days after the procedure. This includes most sports - jogging, golfing, play tennis, and bowling
  • Go up and down the stairs more slowly than usual
  • Slowly start to do more during the week after the procedure, when you should be back to your normal routine
  • Ask your doctor when it is safe to resume sexual activity

If you had a transradial (wrist) procedure

  • Do not move the wrist used in the procedure more than you need to for 24 to 48 hours after the procedure
  • Put soap on your hand or a washcloth and gently cleanse and rinse the area. Do not rub the area
  • Do not lift anything that weighs more than 5kg or push or pull heavy objects for the first 5 to 7 days after the procedure
  • It is ok to take a shower the day after your procedure
  • Expect to feel mild tingling in your hand and tenderness at the insertion site for up to 3 days. If this lasts longer than 3 days or you have other non-emergency symptoms, call your doctor

If your wrist bleeds once you are home, do not panic. Follow these steps to control the bleeding:

  • Wash your hands and place 1 or 2 fingers over the puncture site. Keep pressure on the site to stop the bleeding. You may be able to feel your pulse as you do this
  • After 5 minutes, remove your fingers from the site to see if the bleeding has stopped
  • Once the bleeding has stopped, gently wipe the area clean and cover it with a bandage
  • If the bleeding does not stop after 20 minutes, or if there is a large amount of bleeding or spurting, call 995 (DO NOT drive yourself to the hospital)

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.

  1. 1
    Diet - Consume nutritious food that is good for your heart
  1. 2
    Cardiac 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.

  1. 3
    Medications – 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:

  • Blood thinners –  Aspirin plus Clopidogrel (Plavix) or Ticagrelor (Brilinta)
  • Cholesterol lowering drugs – egs. Atovastatin (Lipitor) or Rosuvastatin (Crestor)
  • Anti-anginal drugs – Nitrates (eg Imdur), Beta-blockers (eg Concor)
  • Risk factor management drugs – Medications for hypertension or diabetes

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.

Key messages

  • Do not stop taking any prescribed medication without talking to your cardiologist
  • Ask your doctor if you have any questions about your medications
  1. 4
    Cardiovascular 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:

  • Stop smoking
  • Choose to consume only nutritious food
  • Be physically active every day
  • Aim for a healthy weight
  • Reduce stress
  • Limit alcohol intake
  • Get enough sleep
  • Ensure that risk factors such as diabetes mellitus, hypertension and high cholesterol are well controlled to targets set by your cardiologist
  1. 5
    Follow-up appointments – Do not default on your reviews
  • Your cardiologist will give you a date for your follow-up appointment
  • You may be required to do a fasting blood test, ECG or echocardiogram during your follow-up visit to assess your condition
  • During this appointment, a general summary of your medical condition including the procedure you underwent, prescribed medications and care plan will be explained to you
  • Please ask your cardiologist if you have any questions about cardiac catheterization, angioplasty or stenting
  • It is important to commit to living a heart-healthy lifestyle. Your cardiologist will work with you to help you achieve your goals, but it is up to you to take your medications as prescribed, make changes in your diet, quit smoking, exercise regularly and keep your follow-up appointments

When to call the doctor

Call your cardiologist if you have the following symptoms:

Site of Catheter insertion

  • Increasing pain, swelling, redness, warmth
  • Pus-like drainage
  • Feelings of coldness, numbness, tingling or excessive swelling on the leg or arm of the catheter insertion site

General symptoms

  • Signs of infection: Fever of 38oC or higher
  • Persistent chest discomfort, shortness of breath, palpitations
  • Inability to urinate or if there is blood in your urine
  • Frequent bruising or blood in your stools

Don't wait for your symptoms to worsen.

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