Coronary Artery Disease
Like any other organ of the body, the heart too requires a healthy supply of oxygen-rich blood for proper functioning. This is provided by arteries in the heart – called coronary arteries, with three of them being major ones. In some people, a cholesterol-rich diet can cause an accumulation of fatty deposits on the inside wall of coronary arteries.
With time, the build-up of deposits narrows down the artery and restricts blood flow to the heart muscles. This condition is called atherosclerosis, and the deposits are called plaque. The area where the deposits are wide and constrict the blood flow is called blockage. Over time, atherosclerosis presents various risks, such as heart attack, stroke, and heart failure. The entire gamut of symptoms and conditions arising out of atherosclerosis is called Coronary Artery Disease (CAD) or Coronary Heart Disease (CHD).
A person can develop one or more blockages in the same artery or multiple arteries of the heart. In the latter case, the condition is called multi-vessel CAD or complex CAD. Treating atherosclerosis involves removing the blockage and widening the arteries so that normal blood flow to the heart can be restored.
Also Read: How does one know if one has a blocked artery?
How is CAD diagnosed?
Most people with CAD develop angina or mild chest pain. The doctor will first ask for an ECG (electrocardiogram) that will show evidence of reduced blood flow in the coronary arteries. If the doctor suspects CAD, he/she will prescribe a treadmill stress test or pharmacological stress test to rule out or confirm CAD.
Medical Therapy: The blockage is gradually reduced by using a medication, changes to the diet, quitting smoking, and undertaking daily exercise. This is what the doctor would recommend if the patient is young, has one or 2 minor blockages, and does not have any other medical condition. However, when medical therapy does not work out, the blockage must be removed by an intervention such as angioplasty or CABG. Incidentally, after these interventions are done, the patient must make the same changes to the lifestyle, which is part of this therapy.
Coronary Artery Bypass Grafting (CABG): Around the early 1960s, a new option for treating atherosclerosis emerged. In this, a piece of a blood vessel taken from another part of the body is stitched above and below the blocked artery (grafting) to re-route (bypass) the blood flow around the blockage. The blood vessel chosen for this procedure may come from the chest wall (mammary artery), the arm (radial artery), or the lower leg (saphenous vein). A third of all CAD cases are treated using the method. With CABG, the recovery is slow, but the chances of a repeat blockage (restenosis) in the same area, or the same artery, are low.
Balloon Angioplasty with stenting (Stenting): This procedure emerged around the early 1980s. In this procedure, a small incision is made in the groin, arm, or lower leg. A catheter is inserted into the blood vessel in the incision and threaded or pushed all the way gently into the heart, into the blocked artery, and the site of the blockage. The tip of the catheter has a metal coil that wraps around a deflated balloon. The balloon is inflated now, which pushes the stent against the deposits, which in turn are pressed onto the arterial wall. The balloon is then deflated, and the catheter is withdrawn. The stent remains in place to ensure the blockage doesn’t develop again. With time, wall tissue starts growing around the stent and holds it in place. Recovery is quick, but many people who have undergone stenting develop a second blockage after some years.
Comparing Angioplasty and CABG
- Type of procedure: A surgical procedure. The surgeon makes an 8 to 10-inch long incision, cuts through the sternum, to access the heart and further, the blocked artery. General anaesthesia is given to the patient. During the procedure, a heart-lung machine maintains circulation in the heart.
- Suitability: If the patient has a blockage in the left anterior descending (LAD) artery, one of the 3 main coronary arteries, stenting will not work, and CABG is inevitable. So also if the person has 1 or more blockages across the 3 main coronary arteries, CABG is unavoidable. And if the person has diabetes, kidney disease, peripheral arterial disease, heart valve disease, a prior incident of heart attack or stroke, CABG is the only option.
- Hospitalization: The person has to stay in the hospital for 3-5 days after the procedure.
- Recovery time: It will take the patient 3 to 6 months to get back to everyday life, depending on the age, number of blockages removed, and other health conditions.
- Post-procedural treatment: The patient will have to make changes to their lifestyle, as described in the earlier part of the article.
- Need for a repeat procedure: A study published in the New England Journal of Medicine in January 2008 compared patients who have had stenting or CABG in the US in the years 2003 and 2004. As per this, the percentage of patients who had a CABG and who needed a repeat procedure within 18 months was just 5.1%.
- Cost: Both the cost of the procedure and cost of CAD-related treatments for the rest of the person’s life is lower for CABG than stenting. However, hospitalization costs are higher due to the more extended stay at the hospital.
Also Read: Life after Bypass Surgery
- Type of procedure: Balloon angioplasty with stenting is a minimally invasive procedure and is performed without anaesthesia. However, if the patient prefers it, a mild sedative can be given to reduce discomfort.
- Suitability: Stenting is ideal when the LAD does not have any blockage, the number and extent of blockages are less, the patient is in the middle-ages, has a healthy BMI, and does not have any co-morbidities. Patients who are frail and elderly, with or without co-morbidities, are also advised stenting as they may not be able to withstand the stress of surgery.
- Hospitalization: The patient is observed for a night and then discharged the next day.
- Recovery time: The patient will be fine in a day and can resume normal life within a week.
- Post-procedural treatment: Patients who have had a drug-eluding stent must take drugs such as clopidogrel and aspirin for almost a year after the procedure. These are given to prevent the formation of blood clots around the stent.
- Need for a repeat procedure: In the same study, explained previously, the percentage of patients who had a stent and who needed a repeat procedure within 18 months was as high as 30.6%.
- Cost: Both the cost of the procedure and cost of CAD-related treatments for the rest of the person’s life are higher for stenting. However, hospitalization costs are minimal due to the short stay at the hospital.
Choosing Between Angioplasty and CABG
The decision to choose between CABG and stenting is a complex one. While some hospitals may ask you for your preference, in most cases, there is no choice. Most cardiologists maintain a score-card to evaluate, which is the better option for the patient. The choice should be left to the cardiologist or cardiac surgeon. Consult a reputed hospital that has qualified and experienced cardiologists on their rolls. These specialists will choose the better option for you and design a course of treatment for quick recovery and rehabilitation.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Karaikudi, Hosur and Salem, the hospital also renders adult and pediatric trauma care.
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