Coronary Heart Disease Surgeries and Procedures

Surgical treatment for coronary heart disease is typically reserved for cases where milder therapies have been ineffective.
Surgical treatment for coronary heart disease is typically reserved for cases where milder therapies have been ineffective.
Publications International, Ltd.

An invasive procedure to treat coronary heart disease may be necessary in people who have severe symptoms that indicate marked impairment of blood flow to the heart. It just may not be possible to wait to determine if a healthy diet and drug therapy are effective.

In such cases, an invasive procedure that immediately restores blood flow to the heart may be necessary. In other cases, after diet and drug therapy have been tried without sufficient success, an invasive procedure may be recommended.

You may have heard about these procedures on the news or read about them in magazines. We'll provide you with in-depth, accurate information that will arm you with the knowledge you need before talking about them with your doctor or undergoing such a procedure.

The first such procedure that we'll discuss is angioplasty, explained on the next page.

This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. Neither the Editors of Consumer Guide (R), Publications International, Ltd., the author nor publisher take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this information. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider. Before undertaking any course of treatment, the reader must seek the advice of their physician or other health care provider.

Angioplasty

In angioplasty, also called percutaneous coronary intervention (PCI), a catheter with a balloon attached is guided through the coronary arteries. When the catheter reaches the site of obstruction where the arteries are narrowed, the balloon is inflated, flattening the plaque against the artery walls and easing the flow of blood.

This procedure is often effective at relieving symptoms, such as angina, that drug therapy alone could not relieve. It is also the preferred alternative when symptoms are not severe enough to warrant the more invasive coronary artery bypass surgery.

In the past, angioplasty failed to keep blood vessels open in approximately 30 percent of cases, requiring a second procedure, called restenosis. Today, however, the success rate is much higher.

This is in part a result of the use of stents. These devices are essentially metal scaffolds that are inserted into the site where the angioplasty was performed. Now, more than 800,000 PCI procedures are performed each year, exceeding the number of coronary artery bypass surgeries.

Most recently, drug-coated stents have been developed. These are designed to deliver medication directly to the narrowed site. The two most frequently used types of drug-coated stents are the Cypher stent, which is coated with the drug sirolimus, and the Taxus stent, which is coated with the drug paclitaxel. In both these stents, most of the drug is released in the first month.

Although drug-coated stents have reduced restenosis after angioplasty, they have been associated with increased blood clots or heart attack when antiplatelet medications, such as aspirin and clopidogrel, are stopped within the first 12 to 18 months after placement.

All elective surgeries should be postponed until at least 6 to 12 months after a drug-coated stent is placed. For unanticipated dental work or surgery, talk with your doctor before stopping antiplatelet medications. Most dental work can be performed while taking aspirin and clopidogrel, but your dentist must pay close attention to any bleeding.

Many surgeries can also be performed while taking aspirin and clopidogrel, but bleeding is usually increased. If emergency surgery necessitates stopping aspirin and clopidogrel, your cardiologist should be notified in order to monitor your condition. For those who have bare metal stents, clopidogrel is often stopped after four weeks and aspirin continued.

Regardless of the success of an angioplasty procedure and the placement of a stent, it is not a substitute for a lifetime plan for controlling blood cholesterol through diet and drug therapy.

In some cases, a patient might benefit more from a coronary bypass surgery than from angioplasty. Find out what happens in this surgery, and when it is recommended, on the next page.

Coronary Artery Bypass Surgery

A coronary artery bypass surgery is performed on one or more of the coronary arteries, which lie on the outer surface of the heart and supply the heart muscle with the oxygen and nutrients it needs. The purpose of the operation is to bypass the obstructed portion of the artery and allow blood to flow freely to the heart muscle.

To bypass the blocked area, the surgeon uses a blood vessel taken from another part of the body, such as the internal mammary artery (located behind the sternum), the radial artery (in the wrist), or saphenous veins (usually taken from the legs).

For use in coronary bypass surgery, arteries are preferred to saphenous veins because they are not as susceptible to atherosclerosis. Moreover, the use of veins requires extremely strict attention to diet, LDL cholesterol, and blood pressure in order to prevent narrowing and eventual closure; quitting smoking is essential.

The decision to undergo coronary bypass surgery instead of an angioplasty should take into account many factors. It's important to determine which arteries are narrowed and to what degree. Coronary bypass surgery is often recommended to people who have a narrowed left main coronary artery or a significantly narrowed left anterior descending (LAD) artery.

The risk of death is greatly increased when these particular arteries are narrowed because they feed other critical arteries. Other people who generally tend to fare better with coronary bypass surgery rather than an angioplasty include those who have serious narrowing in three major coronary blood vessels; multiple narrowing in any blood vessels and reduced ability to pump blood from the left ventricle of the heart; and significant narrowing in two blood vessels and partial narrowing of the LAD.

Other factors to consider before undergoing coronary bypass surgery include advanced age, the individual's anatomy of the heart and surrounding blood vessels, and -- when possible -- the person's preference.

Current evidence suggests that coronary artery bypass surgery is effective for diabetics when complete revascularization (bypassing all the arteries that are significantly narrowed) can be accomplished. However, diabetics experience a higher rate of complications and death due to surgery. Because of this, diabetics should closely monitor and intensively manage their risk factors to reduce the likelihood of revascularization of any kind.

People who have had coronary artery bypass surgery and are recovering should begin an intensive prevention program before going home. Mainstays of the prevention program include drugs such as aspirin, beta blockers, statins, and ACE inhibitors. Patients should also receive counseling on diet and lifestyle changes, such as quitting smoking and exercising regularly.

Cardiac rehabilitation programs can be especially helpful not only for beginning an exercise program but also for help implementing all aspects of the coronary prevention program.

Evaluation for depression is important since it can seriously impair the likelihood that a person will follow the necessary diet and drug regimen. Evidence suggests that selective serotonin reuptake inhibitor (SSRI) antidepressants, such as sertraline and citalopram, can effectively and safely treat depression in people who have had a heart attack. There is no definitive evidence, however, that such treatment reduces future coronary events.

There's also no hard evidence in favor of chelation therapy, the removal of calcium from blood-vessel walls. Find out why people believe in it, and the concerns about this process, on the next page.

Chelation Therapy

Chelation therapy for atherosclerosis refers to the use of a chelating agent called ethylenediaminetetraacetate (EDTA) to remove calcium buildup in fatty plaques in the blood-vessel walls.

One theory suggests that removing calcium from the coronary arteries causes the plaques to break up, which may help ward off or reverse atherosclerosis. Another theory is that EDTA chelation therapy stimulates the release of a hormone that causes calcium removal from plaques or causes a lowering of cholesterol levels. A third theory suggests that chelation therapy reduces the damaging effects of oxygen on blood-vessel walls (called oxidative stress), which, in turn, reduces inflammation in the arteries and improves blood-vessel function.

Despite studies claiming benefit from this therapy, however, critical analysis by respected medical journals has not found convincing evidence that chelation therapy is an effective treatment for atherosclerosis.

A major flaw with studies claiming benefit from chelation therapy was the absence of suitable control groups (people who are like the treatment group in every way except that they did not receive the medication or therapy in question). Without a control group, you don't know if any improvement seen in the treatment group was due to the therapy, the doctor's reassuring manner, or just chance. Another flaw was that the studies were too small to detect benefit from the treatment.

There is also concern about the safety of chelation therapy. EDTA is excreted by the kidney, so it can be toxic to those with impaired kidney function. Chelation therapy might also cause a sudden drop in blood pressure, low blood-calcium levels, fever, vomiting, and a burning sensation where the EDTA is delivered into the veins.

Although good evidence in support of chelation therapy is lacking, that has not stopped some practitioners from recommending it nor has it prevented consumers from using it. In 2003, the National Center for Complementary and Alternative Medicine and the National Heart, Lung, and Blood Institute began the first large-scale clinical trial to determine the safety and efficacy of EDTA chelation therapy in people with coronary heart disease.

The Trial to Assess Chelation Therapy (TACT) is expected to enroll 1,950 heart-attack survivors in more than 100 research sites across the country to determine whether chelation therapy improves the rate of second heart attacks and is safe and effective. The study should conclude in 2010.

Proper diet and exercise will reduce your chance of needing urgent care for coronary heart disease. But if you should ever find yourself in that position, the information in this article will help you understand what you're about to undergo.

ABOUT THE AUTHORS

Dr. Neil Stone is a professor of clinical medicine in cardiology at the Feinberg School of Medicine of Northwestern University and a practicing internist-cardiologist-lipidologist at Northwestern Memorial Hospital. He also serves as the Medical Director of the Vascular Center for the Bluhm Cardiovascular Institute. Dr. Stone was a member of the first and third National Cholesterol Education Program Adult Treatment Panels and a past chairman of the American Heart Association Nutrition Committee and Clinical Affairs Committee.

Adrienne Forman, M.S., R.D., is a consultant and freelance writer, specializing in nutrition and health communications. She is the editor of Shape Up America! newsletter, an online publication, and a former contributing editor of Environmental Nutrition newsletter for 14 years. Adrienne is a former Senior Nutritionist at Weight Watchers International, where she was instrumental in creating multiple weight-loss programs, including their popular Points® program.

 

This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. Neither the Editors of Consumer Guide (R), Publications International, Ltd., the author nor publisher take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this information. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider. Before undertaking any course of treatment, the reader must seek the advice of their physician or other health care provider.

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