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The heart is supplied by three major coronary arteries and their branches (as described

in the cardiac cath section). Atherosclerosis produces discrete (confined) or scattered


areas of blockage within a coronary artery. When the blockages are large enough, they
reduce blood supply to heart muscle and produce angina. The tests used to make the
diagnosis of coronary artery disease and its medical treatment have been discussed
elsewhere. Some patients with coronary artery disease may require surgery. Many
patients with serious disease or those who fail on medical therapy are treated with a
"needle hole" or "percutaneous" (through the skin) procedure that is performed in the
cardiac cath laboratory. Angioplasty is one of these procedures. It was introduced to the
world by Dr. Andreas Gruentzig in the mid to late 1970's and is widely used today.

What is PTCA or Angioplasty? Angioplasty is a technique used to dilate an area of


arterial blockage with the help of a catheter that has an inflatable small sausage-shaped
balloon at its tip.
Since the balloon catheter is introduced through the skin of the groin, and sometimes the
arm ( percutaneous = through the skin), is placed within a blood vessel (transluminal = in
the channel or lumen of a blood vessel) and is applied in the treatment of coronary
arteries, the technique is also called PTCA or Percutaneous Transluminal Coronary
Angioplasty.

Angioplasty physically opens the channel of diseased arterial segments (see below),
relieves the recurrence of chest pain, increases the quality of life and reduces other
complications of the disease. Since it is performed through a little needle hole in the groin
(or sometimes the arm) it is much less invasive than surgery and can be repeated more
often should the patient develop disease in the same, or another, artery in the future.

How is PTCA performed? Prior to performing PTCA, the location and type of blockage
plus the shape and size the coronary arteries have to be defined. This helps the
cardiologist decide whether it is appropriate to proceed with angioplasty or to consider
other treatment options such as stenting, atherectomy, medications or surgery. Cardiac
catheterization (cath) is a specialized study of the heart during which a catheter or thin
hollow flexible tube is inserted into the artery of the groin or arm. Under x-ray
visualization, the tip of the catheter is guided to the heart. Pressures are measured and an
x-ray angiogram (angio) or movie of the heart and blood vessels is obtained while an
iodine- containing colorless "dye" or contrast material is injected into the artery through a
catheter. The iodinated solution blocks the passage of x-rays and causes the coronary
arteries to be visualized in the angios. In other words, coronary arteries are not ordinarily
visible on x-ray film. However, they can be made temporarily seem by filling them with a
contrast solution that blocks x-ray.

As discussed in the cardiac cath section, a sheath is introduced in the groin (or
occasionally in the arm). Through this sheath, a long, flexible, soft plastic tube or guiding
catheter is advanced and the tip positioned into the opening or mouth of the coronary
artery. In the picture below, the catheter tip is positioned in the mouth of the left main
coronary artery.
The tube measures 2 to 3 mm in diameter. The tip of the catheter is directed or controlled
when the cardiologist gently advances and rotates the end of the catheter that sits outside
the patient.

Once the catheter tip is seated within the opening of the coronary artery, x-ray movie
pictures are recorded during the injection of contrast material or "dye."

After evaluating the x-ray movie pictures, the cardiologist estimates the size of the
coronary artery and selects the type of balloon catheter and wire that will be used during
the case. Heparin (a "blood thinner" or medicine used to prevent the formation of clots) is
given.

The guide wire which is an extremely thin wire with a flexible tip is inserted into
through the catheter and into the coronary artery. The tip of the wire is then guided across
the blockage and advanced beyond it (see animation, top-right). The cardiologist controls
the movement and direction of the guide wire by gently manipulating the end that sits
outside the patient. This wire now serves as a "guide" or rail over which the balloon
catheter can be delivered. The tip of the balloon catheter is then passed over the guide
wire and positioned across the lesion or blockage.

A deflated sausage-shaped balloon is located on the tip of the catheter shaft. It is


inflated by connecting it to a special handheld syringe pump. A mixture of saline and
contrast material is used to inflate the balloon. The contrast material helps to visualize the
balloon when it is inflated. The balloon catheter also has metallic markers (either at the
center or on either side of the balloon). This helps the cardiologist know the location of
the otherwise "invisible" balloon.

Inflation is initially carried out at a pressure of 1 to 2 times that of the atmosphere and
then sequential and gradually increased to 8 - 12 and sometimes as high as 20
atmospheres, depending upon the type of balloon that is used. The handheld inflation
syringe has markers that are used to determine the pressure. The balloon is kept inflated
for 1/2 to 2 minutes and then deflated until the next inflation is used. Intermittent
inflation allows blood flow through the artery during the time that the balloon is deflated.
A nitroglycerin solution may be injected to prevent spasm of the artery.

As the balloon is inflated, it compresses the atheroma and plaque that make up the
coronary blockage. The process is similar to sticking a clump of a spongy plastic "dough"
to the inside wall of a plastic tube (with the help of a super-type glue) to create a
blockage that restricts the flow of water. The "dough" is then compressed with a balloon
tipped catheter. During each inflation, the "dough" is compressed or "squashed" even
more. This is continued until the opening of the tube at that level of the blockage
becomes closer to the tube not covered with "dough." Unfortunately, the obstruction
material of atherosclerosis is composed of soft fatty atheroma, firm plaque and a medium
consistency mixture of the two. These material resist expansion by a balloon in different
ways. Soft material is compressed easily while firm matter compresses to a lesser degree
and may demonstrate cracks following expansion by a balloon. That is why the opening
created by a balloon is not always round and smooth.

It is important to remember that the balloon of angioplasty catheters is not made of


rubber used in toy balloons. Special material is employed so that the catheter balloon
inflates to a predictable size at a given pressure. For example, a particular brand of
balloon will open up to a 2 mm diameter with 8 atmospheres of pressure and 2 1/4 mm at
16 atmospheres.

The picture on the left shows the rounded unobstructed channel of a normal coronary
artery (cross-sectional view). The middle picture shows that the channel (through which
blood flows) is significantly reduced by a blockage. The diagram on the right shows an
increased opening after the blockage was dilated or opened up with balloon angioplasty.

The patient remains awake throughout the procedure and mild sedation is used to ensure
relaxation and comfort. The deflated balloon and wire are withdrawn when the
cardiologist is satisfied with the results. If the result is unsatisfactory, a second balloon or
even a stent may be considered. Final angiograms or movie x-ray pictures are taken upon
completion of the case. The guiding catheter is then withdrawn.

The sheath is secured to the groin with a suture and the patient is sent to his or her
room. The sheath is removed when the effect of Heparin wears off. This is determined by
obtaining blood tests at specified intervals. Other medications that prevent blood-clots
may be used in some cases. Pressure is applied to the groin with a clamp. Once it is
confirmed that there is no bleeding, a sandbag or ice bag is placed over the groin.

After approximately 6 hours, the patient is ambulated or allowed to walk with


assistance and is usually discharged the following morning. A Band-Aid or small
dressing is applied over the tiny needle hole. Slight bruising around the site is not
uncommon.

In some labs, a sealant device is applied in the cath lab after removal of the sheath.

For a description of the equipment, preparation and experiences during the procedure,
please review the cardiac cath section. It is not uncommon for patients to experience
chest discomfort while the balloon is inflated. This usually resolves when the balloon is
deflated. Patients who are uncomfortable can be given intravenous medication to alleviate
this problem.

Results of balloon Angioplasty:

The video on the left shows an 80% blockage in the proximal portion of the left anterior
descending coronary artery (arrow). The video to its right shows no remaining blockage
after the patient was treated with balloon angioplasty.

How long does the procedure take? It can take anywhere from 30 minutes to a three
hours to perform the entire case. The duration is dependent upon the technical difficulty
of the case and the number of balloon catheters that have to be employed.

How safe is the procedure? In the hands of experienced cardiologists, and with
availability of modern day technology, it is estimated that the risk of death is during an
angioplasty procedure is usually less than 1%, while the chance of requiring emergency
bypass surgery is around 2% or less. It is a relatively safe procedure and is carried out all
over the world. An "out patient" or an inpatient uncomplicated angioplasty usually
require 23 hours or less of hospitalization after the procedure.

The risk of a other serious complication is estimated to be less than 4 and probably
around 1 to 2 per thousand, and similar to that described for cardiac cath. The risk of a
heart attack and bleeding that requires a blood transfusion is increased when compared to
cardiac cath. However, the risks are relatively low and acceptable in most cases when one
balances the potential benefit against the expected risk (risk-benefit ratio).

The aggravation of kidney function (particularly in diabetics and those with prior kidney
disease) is higher than that expected with cardiac cath because of the larger amount of
contrast material that is usually required. In such cases, the cardiologist takes extra
precautions to prevent this possible complication.

What is a Coronary Artery stent? A coronary stent is stainless tube with slots. It is
mounted on a balloon catheter in a "crimped" or collapsed state. When the balloon of is
inflated, the stent expands or opens up and pushes itself against the inner wall of the
coronary artery. This holds the artery open when the balloon is deflated and removed.
Coronary artery stents were designed to overcome some of the short comings of
angioplasty. Angioplasty is a technique that is used to dilate an area of arterial blockage
with the help of a catheter with an inflatable, small, sausage-shaped balloon at its tip.
Although introduced over two decades ago, angioplasty continues to be the most
frequently employed procedure in the cardiac cath lab (either by its self, or in conjunction
with other procedures such as coronary stenting).

However, coronary angioplasty has two shortcomings. Firstly, the opening created by
the procedure is not very smooth because the balloon does not evenly expand all areas
that have different degrees of hardness (atheroma is soft, plaques are hard and mixture of
the two have a medium and uneven degree of hardness). This produces a channel with an
irregular shape and a rough surface that is covered with superficial or deep cracks. The
irregular surface and the cracks on the inner lining of the artery increases the risk of
complete arterial blockage in a very small number of patients. The picture on the left
(below) shows a blockage prior to angioplasty, while the picture in the middle
demonstrates the artists rendition of the angioplasty results.

Secondly, some of the compressed material tends to "spring back" to some degree. This
is known as "recoil." Recoil causes the channel to become smaller shortly after being
enlarged by balloon expansion. Moreover, the material within the expanded channel
starts to multiply after the channel is expanded. This causes a gradual build-up of
material. In 30-60% of cases, the build-up of material can be large enough to cause the
blockage to return to its original (or worse) severity. This occurs over a 6 week to 6
month duration of time and is known as restenosis.

The picture on the left (above) shows a cross-section of a coronary artery at the level of
a blockage or stenosis. The diagram on the extreme right shows an increased opening
after the blockage was treated with a coronary stent. A stent is a metal "mesh" that is
mounted on an angioplasty balloon. When the balloon is inflated, it expands the stent and
opens up the diseased segment into a rounder, bigger and smoother opening (compared to
angioplasty, which is shown in the middle picture as having a more "frayed" appearance),
Stents induce a more predictable and satisfactory result, reduces the risk of the artery
abruptly closing off during the procedure and also decreases the chance of restenosis
(recurrence of the blockage) by nearly 50% (from 30-50% in cases of angiopalsty, down
to 15-25% in cases of stents).

Like angioplasty, coronary stents physically opens the channel of diseased arterial
segments, relieves the recurrence of chest pain, increases the quality of life and reduces
other complications of the disease. Since it is performed through a little needle hole in the
groin (or sometimes the arm) it is much less invasive than surgery and can be treated with
another needle or percutaneous procedure should the patient develop disease in the same,
or another, artery in the future.
How is Coronary Artery Stenting performed? Prior to performing stenting, the
location and type of blockage plus the shape and size the coronary arteries have to be
defined. This helps the cardiologist decide whether it is appropriate to proceed with
angioplasty or to consider other treatment options such angioplasty, atherectomy,
medications or surgery. Cardiac catheterization (cath) is a specialized study of the heart
during which a catheter or thin hollow flexible tube is inserted into the artery of the groin
or arm. Under x-ray visualization, the tip of the catheter is guided to the heart. Pressures
are measured and an x-ray angiogram (angio) or movie of the heart and blood vessels is
obtained while an iodine- containing colorless "dye" or contrast material is injected into
the artery through a catheter. The iodinated solution blocks the passage of x-rays and
causes the coronary arteries to be visualized in the angios. In other words, coronary
arteries are not ordinarily visible on x-ray film. However, they can be made temporarily
seem by filling them with a contrast solution that blocks x-ray.

As discussed in the cardiac cath section, a sheath is introduced in the groin (or
occasionally in the arm). Through this sheath, a long, flexible, soft plastic tube or guiding
catheter is advanced and the tip positioned into the opening or mouth of the coronary
artery. In the picture below, the catheter tip is positioned in the mouth of the left main
coronary artery.
The tube measures 2 to 3 mm in diameter. The tip of the catheter is directed or controlled
when the cardiologist gently advances and rotates the end of the catheter that sits outside
the patient.

Once the catheter tip is seated within the opening of the coronary artery, x-ray movie
pictures are recorded during the injection of contrast material or "dye."

After evaluating the x-ray movie pictures, the cardiologist estimates the size of the
coronary artery and selects the type of balloon catheter and guide wire that will be used
during the case. Heparin (a "blood thinner" or medicine used to prevent the formation of
clots is given. In most cases, coronary stenting is preceded by angioplasty. This is known
as "pre-dilation." It helps open up the blockage area, and makes it easier to deliver the
stent.

The guide wire which is an extremely thin wire with a flexible tip is inserted into the
catheter. The tip of the wire is then guided across the blockage and advanced beyond it.
This wire now serves as a "guide" or rail over which the balloon catheter is passed. The
tip of the stent balloon catheter is then positioned across the lesion. The balloon is
situated on the tip of the catheter shaft and is inflated by connecting it to a special hand-
held syringe pump. A mixture of saline and contrast material is used to inflate the
balloon. The balloon catheter has metallic markers (at either side of the balloon). The
unexpanded stent is mounted just inside these visible metallic markers that helps the
cardiologist know the location of the otherwise poorly visible stent.

Inflation is initially carried out at a pressure of 1 - 2 times that of the atmosphere and
then increased to 8 - 12 and sometimes as high as 20 atmospheres, depending upon the
type of stent that is used. The handheld inflation syringe has markers that are used to
determine the pressure. The balloon is kept inflated for 30 to 60 seconds and then
deflated. The expanded stent is embedded into the wall of the diseased artery, holding it
open. If not satisfied by the results, the cardiologist will further expand the stent using
another balloon (frequently it is the same balloon catheter that was used for "pre-
dilation.".

Results of coronary artery stenting:

The video on the left (above) shows a 95% blockage in the proximal portion of the left
anterior descending coronary artery (arrow). The video to its right shows no remaining
blockage after the patient was treated with a coronary artery stent.

The patient remains awake throughout the procedure and mild sedation is used to
ensure relaxation and comfort. The deflated balloon and wire are withdrawn when the
cardiologist is satisfied with the results.

The sheath is secured to the groin and the patient is sent to his or her room. The sheath
is removed when the effect of Heparin wears off. This is determined by obtaining blood
tests at specified intervals. Pressure is applied to the groin with a clamp. Once it is
confirmed that there is no bleeding, a sandbag or ice bag is placed over the groin.
After approximately 6 hours, the patient is ambulated or allowed to walk with
assistance and is usually discharged the following morning. A Band-Aid or small
dressing is applied over the tiny needle hole. Slight bruising around the site is not
uncommon.
In some labs, a sealant device is applied in the cath lab after removal of the sheath.

For a description of the equipment, preparation and experiences during the procedure,
please review the cardiac cath section. It is not uncommon for patients to experience
chest discomfort while the balloon is inflated. This usually resolves when the balloon is
deflated. Patients who are uncomfortable can be given intravenous medication to alleviate
this problem.

How long does the procedure take? It can take anywhere from 30 minutes to an hour to
perform the entire case. The duration is dependent upon the technical difficulty of the
case and the number of balloon catheters that have to be employed.

How safe is the procedure? In the hands of experienced cardiologists, and with
availability of modern day technology, it is estimated that the risk of death is during a
stent procedure is usually less than 1%, while the chance of requiring emergency bypass
surgery is around 2% or less. It is a relatively safe procedure and is carried out all over
the world. An "out patient" or an inpatient uncomplicated stent case usually require 23
hours or less of hospitalization after the procedure.

The risk of a other serious complication is estimated to be less than 4 and probably
around 1 to 2 per thousand, and similar to that described for cardiac cath. The risk of a
heart attack and bleeding that requires a blood transfusion is increased when compared to
cardiac cath. However, the risks are relatively low and acceptable in most cases when one
balances the potential benefit against the expected risk (risk-benefit ratio).

The aggravation of kidney function (particularly in diabetics and those with prior
kidney disease) is higher than that expected with cardiac cath because of the larger
amount of contrast material that is usually required. In such cases, the cardiologist takes
extra precautions to prevent this possible complication.

The stent is completely covered by natural tissue in a matter of 4 - 6 weeks.and the risk
of clot formation is nearly absent by that time. In very few cases (1 chance out of 200) a
clot may form during the first two weeks after a stent procedure). Such patients develop
symptoms of a heart attack. With prompt treatment, the majority of these stents can be
reopened.

If coronary artery stenting is superior to angioplasty, why is it not used in every


single case? Good question! If stents could be delivered to every lesion, and if it had the
same good short and long term results in every case, it would be used in 100% cases of
angioplasty. However, this is not the case. Stents are difficult to deliver across tight bends
in blood vessels (particularly if they have a lot of calcium deposits in the wall) and are
not usable in very small blood vessels. There are other types of technical considerations
that also come into play. Today, it is estimated that stents are employed in nearly 50-75%
of cases.

What special treatment is needed after a coronary stent procedure? Coronary artery
stents are foreign metallic objects that are left inside the coronary artery. Special
precautions have to be taken to prevent them from being covered with clot. Medications
that make platelets less active has been found to be extremely effective in preventing
clots. A combination of soluble aspirin (Bayer Aspirin* is an example) and Plavix* is
very popular in the USA. (* = Trade Names of the manufacturers). The medications are
started either before or during the procedure. Aspirin is continued indefinitely if the
patient is not allergic to the medication and does not develop any problems with it.
Plavix* is usually stopped in 4 - 6 weeks because the stent is usually completely covered
by natural tissue during that period and the risk of clot formation is nearly absent by that
time.

If patients are allergic to aspirin or Plavix(R) or are unable to take medication because
of bleeding or other problems, the cardiologist may employ alternative medications
(depending upon the problem) and even delay or avoid the use of a stent.

In 1977 PTCA or balloon angioplasty was introduced as a viable and useful method for
treating coronary artery blockages. A deflated balloon was mounted over a skinny
catheter and delivered to the coronary artery blockage over a flexible guide wire. The
balloon was inflated for about 30 to 60 seconds to open up the blocked passage.
However, it suffered from a disadvantage. Although the results looked very good
immediately after deflation and removal of the balloon catheter, the blockage would
partially return, similar to a sponge becoming larger after being squeezed. This is known
as "recoil." Recoil causes the channel to become smaller after having been enlarged by
balloon expansion. In other words, a 90% blockage may improve to 20% immediately
after PTCA. However, recoil may cause the blockage to worsen and become 30-50% in
severity within 15-30 minutes.

Approximately 15 years later, in 1993, coronary stent were introduced to combat


"recoil." A stent is a stainless tube with slots. It is mounted on a balloon catheter in a
"crimped" or collapsed state. When the balloon is inflated, the stent expands or opens up
and pushes itself against the coronary artery blockage. This holds the artery open after the
balloon is deflated and removed. Stents behave like a cage that holds the expanded
material in place and markedly reduces the amount of recoil.
When the balloon is inflated, it expands the stent and opens up the diseased segment
into a rounder, bigger and smoother opening (compared to angioplasty, which is shown in
the middle picture, above, as having a more "frayed" appearance), Stents induce a more
predictable and satisfactory result. It reduces the risk of the artery abruptly closing off
during the procedure and also decreases the chance of restenosis (recurrence of the
blockage) by nearly 50% (from 30-50% in cases of angiopalsty, down to 15-25% in cases
of stents).

Unfortunately, the material within the expanded channel starts to multiply within a
few days. This creates a gradual build-up of material that grows through the slots or holes
within the stent tube. In 30-60% of cases, the build-up of material can be large enough to
cause the blockage to return to its original (or worse) severity in a matter of 6 weeks to 6
months. This known as restenosis.

In April 2003, the U.S. Food and Drug Administration (FDA) approved the first drug-
eluting stent to open clogged coronary arteries. . The new stent slowly releases a drug,
and has been shown in clinical studies to significantly reduce the rate of re-blockage that
occurs with existing stents and angioplasty procedures. The approval was influenced by a
U.S. study (called the SIRIUS study), 1058 patients received either the Cypher™ stent or
an uncoated conventional stainless steel stent. The Cypher™ Sirolimus-eluting Stent is
manufactured and marketed by Cordis pursuant to a license from Wyeth Pharmaceuticals.
Sirolimus, the active drug released from the stent, is a naturally occurring substance that
reduces the reproduction of tissue that make-up the bulk of restenosis. The drug is
cytostatic. Unlike a cytotoxic drug, which kills cells, a cytostatic agent prevents cells
from dividing without destroying them, leaving them in a resting, state.

The study demonstrated that after nine months, the patients who received the drug-
eluting stent had a significantly lower rate of repeat procedures than patients who
received the uncoated stent (4.2% versus 16.8%). Also, patients treated with the drug-
eluting stent had a restenosis rate of 8.9%, compared to 36.3% in the patients who
received an uncoated stent. The combined occurrence of repeat angioplasty, bypass
surgery, heart attacks and death was 8.8% for drug-eluting stent patients and 21% for the
uncoated stent patients.

The drug-coated stents are significantly more costly than non-coated stents. However,
economic analysis performed independently by researchers such as Dr. David J. Cohen of
the Harvard Clinical Research Institute (reported at the American College of Cardiology
52nd Scientific Session in Chicago on March 31, 2003) have confirmed the cost-
effectiveness of the CYPHER™ drug-eluting coronary stent. Dr. Cohen used actual
hospital in-patient and out-patient cost data, beginning with the period of initial
hospitalization and ending one year following stent implantation.
He reported that, "Over the one-year follow-up period, patients who received the
CYPHER™ Stent showed substantial reductions in the need for repeat treatments and re
hospitalization, translating into substantial post-treatment healthcare savings," said Dr.
Cohen. "During 12-month follow-up, for every 100 patients treated with the CYPHER™
Stent, there were 19 fewer revascularization procedures and 25 fewer hospital admissions
than with the conventional stent."

In March 2004, Boston Scientific Corporation received approval from the FDA to
market its TAXUS™ Express2™ paclitaxel-eluting coronary stent system after
demonstrating a significant reduction in the restenosis rate. Other companies, such as
Medtronic, are carrying out clinical trials with other types of drug-eluting stents. Insertion
of the drug-eluting stent is similar to that of the conventional coronary stent (click on the
high-lighted red text to review details of the procedure.

Drug eluting stents and late thrombosis or clot formation: Bare-metal or non-drug coated
stents are usually fully coated by body tissue within a few weeks. Once this occurs the
stent becomes more resistant to clots and Plavix* can usually be discontinued about 2
months after it is deployed or put in place.

In contrast, drug eluting stents (DES) do not become fully coated with normal tissue
for 6 to 12 months, or even longer. Discontinuation of Plavix* prior to this time can result
in clot formation and a heart attack. Thus, it is extremely important that patients with a
stent (particularly DES) should not stop taking Plavix* until after seeking approval from
their cardiologist.

Angina
Medical Treatment of Angina
Heart Attack

The heart is a muscular organ that pumps blood to the body at an average of 72 times
per minute. Oxygen and nutrients serve as a fuel supply to the pump and are carried to
heart in the form of blood that flows through the coronary arteries. Thus, the coronary
arteries serve as fuel pipe lines to the heart muscle.

The three major coronary arteries (Left Anterior Descending (LAD), Circumflex (Circ)
and Right Coronary Artery (RCA)) and their respective branches each supply a
designated portion of the heart, as follows: The LAD supplies blood to the front (anterior)
portion of the heart and the septum (muscle partition that separates the Left Ventricle
(LV) and Right Ventricle (RV)). The Circ supplies the back (posterior) portion of the LV.
The RCA supplies the bottom (inferior) portion of the ventricle and also the RV in 90%
of cases. In the other 10%, the Circ sends a branch to the inferior wall of the LV.
Coronary arteries have muscle fibers within their walls. By contracting the muscle, the
artery can reduce blood flow; relaxing the muscle increases flow. In this way, the
coronary arteries can regulate blood flow to different portions of the heart. Occasionally,
the muscle within a coronary artery may go into spasm and markedly reduce blood flow
to the heart muscle. This condition is known as coronary spasm. Typically, the chest
discomfort of coronary artery spasm occurs at rest, and usually during the early morning
hours. When the spasm is relieved (spontaneously or with the use of medications), the
blood vessel goes back to its normal appearance and function. A temporary decrease in
blood supply can cause chest discomfort while a persistent decrease can result in
permanent muscle damage or a heart attack.

Atherosclerosis is by far the commonest cause of coronary artery blockage. Unlike


coronary spasm which creates a temporary blockage, atherosclerosis results in a fixed
blockage. Occasionally, atherosclerosis may be accompanied by coronary spasm. The
diagrams below show the various stages of progression of atherosclerosis and
development of coronary artery blockages. The round picture on the left of each
illustration is a cross-sectional view of the coronary artery, while the picture on the right
is a longitudinal section at the same level.

The inner lining of the normal coronary artery is smooth and free of blockages or
obstructions.
However, as we get older, lipids or fatty substances (cholesterol and triglycerides) are
deposited as fatty streaks. The streaks are only minimally raised and thus do not produce
any obstruction or symptoms.

Patients with one or more risk factors for CAD are susceptible to the increased buildup
of fatty layers, known as atheroma (pronounced athe-a-roma). This buildup of material
begins to encroach upon the inner channel and starts to interfere with the free flow of
blood through the coronary artery.

Major risk factors for developing CAD include:

• Hyperlipidemia (high cholesterol level, particularly the "bad" component known


as Low-Density Lipoprotein (LDL))
• High blood pressure
• Diabetes
• Cigarette smoking
• Strong family history of CAD
• Male gender, obesity, age above 50 years, lack of exercise, stress and tension can
also predispose to the development of atherosclerosis
The deposit of atheroma within the inner lining of arteries is called atherosclerosis
(pronounced ath-row-sklee-rosis). It is estimated that 1/3 of adult Americans develop
some form of CAD.

Significant atherosclerosis may be confined to the coronary arteries or may be associated


with blockages within the arteries of the neck and those supplying blood to the lower
limbs (legs)

As atherosclerosis progresses, fibers begin to grow into and around the fatty layers of
atheroma, causing the blockage to harden and turn into a plaque (pronounced plak). The
enlarging plaque (above) increases the encroachment into the inner channel of the
coronary artery. When the channel is reduced by more than 50% (of the diameter) the
artery may become obstructed enough to decrease blood flow to the heart muscle during
times of increased need (exercise, emotional stress, etc.). During such times, the blood
pressure and heart rate are both elevated and increase the need of oxygen and nutrients by
the heart muscle.

The imbalance between the supply and demand of oxygen can cause chest discomfort
(tightness, fullness, heaviness or pain) in the center of the chest and/or over the left
breast). This is known as angina (pronounced an-ji-na) or angina pectoris. When the
coronary artery blockage is severe enough to completely cut off the supply of oxygen and
nutrients to the heart muscle, a heart attack can result. However, atherosclerosis may
maintain a stable pattern for several years or even decades if the plaques grow slowly or
remain relatively stationary. These patients may not notice worsening of angina during
the time of stability and are said to have stable angina.
In other cases, plaques within the inner lining of the coronary artery may develop a
slight crack or rupture. Note that the rupture involves only the surface and does not go
through the wall of the artery. It is similar to a superficial crack on the plaster of a
swimming pool lining, and blood does not escape out of the artery. Plaque rupture
stimulates the production of blood clots that tries to seal off the superficial crack. The clot
also gets into the crack and causes it to rise and further obstruct the channel of the artery.
The sudden increase in the obstruction caused by the raised ruptured plaque and
associated clot can transform a mild blockage into a critical one within a matter of hours
(above). The decrease in blood flow to the heart muscle is severely reduced and the
patient begins to have severe and prolonged chest pain that occurs at rest and may even
awaken him or her from a sound sleep. This is known as unstable angina. If the clot does
not fully close off the channel of the artery (as in the example above) enough blood flow
is maintained to the heart muscle, and a heart attack may not develop if appropriate and
prompt treatment is employed.

However, the clot may continue to grow in many cases. This can completely fill the
open channel of the artery (above) and cut off blood flow to the part of the heart muscle
that it supplies. Without oxygen and nutrients, the patient suffers from a heart attack and
the involved heart muscle can get permanently damaged. The good news is that there are
several forms of treatment that can get rid of the blood clot and restore flow across the
artery. However, this can only be employed if the patient is rushed to the emergency
room of the nearest hospital. Every minute counts in salvaging heart muscle.
Coronary artery blockages and heart attacks may also be seen in patients who use
"Crack" cocaine. This is becoming the commonest cause of heart attacks in young adults
who are treated in emergency rooms in the usa.

Angina 1/2
Coronary Artery Disease
Medical Treatment of Angina
Heart Attack

Angina (pronounced an-ji-na) or angina pectoris is produced when the supply of


oxygen that is carried by blood is unable to meet the demands of the heart muscle. The
decreased supply of blood is created by an obstruction within the coronary artery which
impedes blood flow across it. Atherosclerosis is the commonest cause of obstruction.
However, obstruction may also result from coronary artery spasm or the use of "crack"
cocaine. Angina pectoris is a recurring symptom and usually occurs in the form of chest
discomfort (tightness, fullness, squeezing, heaviness, burning or pain) in the center of the
chest and /or over the left breast). The discomfort may move to the left shoulder and arm
(although it may move to both shoulders/arms, throat, jaw, or even the lower portion of
the chest or upper abdomen). It may be accompanied by shortness of breath, sweating,
weakness, dizziness or nausea, or numbness in the shoulders, arms and hands. When the
build up of plaque is gradual, the patient's symptoms are relatively predictable and stable.
Such patient's usually have symptoms that are provoked by specific levels of exercise.
They are generally brief, last only 2-3 minutes, and subside promptly with cessation of
exercise or following the use of a nitroglycerin tablet. This pattern of pain is known as
stable angina. The partial and temporary decrease in oxygen supply to the heart muscle
does not generally cause permanent damage (unlike a heart attack).

Some patients may have atypical (not typical) symptoms. For example, the pain may be
confined to left shoulder, throat, jaw, or between the shoulder blades. Others may have
shortness of breath or sudden weakness, while approximately 10% may have no
symptoms, even when the heart is severely stressed or undergoing a heart attack. Such
patients are said to have a defective warning system. Diabetic patients are more prone to
have atypical or no symptoms.

Because there are several causes of chest pain that are unrelated to the heart, many
patients tend to ignore their symptoms attributing it to heartburn, mitral valve prolapse, a
gall bladder attack, muscle sprain, etc. If you have risk factors for coronary artery disease
and are having unusual symptoms suggestive of angina or a heart attack, make sure that
you consult your doctor about your complaints.

Angina 2/2
Coronary Artery Disease
Medical Treatment of Angina
Heart Attack

The following section will walk you through the various phases of atherosclerosis. The
following "lecture" describes various phases of the disease. The pictures will change
automatically during the audio presentation. You can play, stop, and rewind the
animation/narration by clicking on the buttons below.

Atherosclerosis begins with the deposition of fatty streaks on the inner lining of the
artery. Additional deposits lead to a bulky atheroma that begins to encroach into the
channel of the coronary artery. Fibers begin to grow into the atheroma causing harder
plaques. The plaque of atherosclerosis may develop a crack on its surface. This is known
as plaque rupture which can result in the deposit of a blood clot at the site of the blockage.
If the blood clot totally blocks flow to the heart muscle, a heart attack usually results.

However, if the clot causes a partial blockage, the patient may develop unstable angina.
Such patients have prolonged, frequent and more severe episodes of angina. The
discomfort may be the patient's first symptom (in which case it is called new onset
angina). In other cases, stable angina gradually or suddenly changes into a pattern of
unstable angina.

The chest discomfort of unstable angina may become more frequent, last longer, be more
intense, be brought on by lesser degrees of exertion (compared to prior symptoms), appear
at rest or even awaken the patient from a sound sleep. It is called unstable angina because
many untreated patients end up having a heart attack. Unstable angina may also occur in
the absence of a blood clot if the severity of the blockage (due to the atheroma and
plaques) becomes severe enough to cause a drastic decrease in blood supply to the heart
muscle.

Click here to review the Medical Treatment of Angina

As mentioned earlier, angina occurs when the coronary artery is unable to supply the
demands of the heart muscle. Thus, it seems logical that the patient's symptoms would
improve only if one was able to increase blood supply or decrease the oxygen needs of
the heart muscle, or achieve a combination of the two. Listed below are medications
commonly used in the treatment of angina:

Nitroglycerin and long acting nitrates: Nitroglycerin (NTG) tablets placed under the
tongue (known as sublingual; sub=under and lingua=tongue), is a very effective means of
treating angina. The tablet dissolves under the tongue and may have a slightly sharp,
burning or tingling taste. Tablets which have this taste when fresh but subsequently
become tasteless may indicate loss of effectiveness and potency. They need to be
replaced by a fresh supply when they pass the expiration date printed on the bottle label;
usually a few months after purchase. NTG is also available in the form of a spray. This
spray pump has the advantage of maintaining its potency for years instead of months.

NTG placed under the tongue dissolves quickly and demonstrates a beneficial effect
within a minute or two. It works by dilating the coronary artery and thus improving the
supply of blood and oxygen to the heart muscle. NTG also dilates (opens up) the veins
and arteries of the body. Dilated veins decrease the filling of the left ventricle (LV),
which in turn reduces its workload. On the other hand, dilated arteries of the body
reduces the blood pressure and the resistance that the LV has to overcome in pumping
blood through those arteries. A single NTG tablet should be placed under the tongue if
angina persists beyond a few minutes after stopping activity. If the pain is unrelieved, a
second tablet is used after 5 minutes. This is repeated at 5 minute intervals, if pain
persists. It is wise to seek medical attention if angina is not completely resolved by the
fourth tablets. Consecutive tablets of NTG may cause dizziness if it significantly lowers
the blood pressure. In such cases, the patient should sit or lie down. Persistence of angina
after the use of four NTG tablets at 5 minute intervals should prompt a phone call to your
doctor. Most patients with established or suspected coronary artery disease will be
advised to go to the emergency room or a physician's office, depending upon the specific
case.

NTG tablets placed under the tongue are short acting and lasts only 5 to 10 minutes,
which is usually a sufficient amount of time to relieve angina. However, a different form
of NTG is needed for preventing angina from coming on. They are known as long acting
nitrates. Long acting nitrates are available in the form of pills that are taken one to three
times a day (depending upon the type that is prescribed) , a patch that is applied to the
skin in the morning and removed at night, or an ointment that is placed on the skin three
to four times a day. Patients on long acting nitrates will need to continue using NTG
under the tongue if angina occurs.

Beta Blockers: The heart rate and blood pressure are elevated when the body releases
increased amounts of adrenaline under moments of exertion and emotional stress.
Adrenaline the left ventricle contracts more vigorously to provide the body with more
blood flow during the period of activity and stress. The increased blood pressure, faster
heart rate and more forceful pumping of the left ventricle all increase the need of oxygen
by the heart. In patients with coronary artery disease, angina occurs if the supply of
oxygen and blood cannot keep up with this increased demand

A class of medications known as beta blockers partially "insulates" the heart and blood
vessels from the effects of adrenaline. This lowers the blood pressure, slows the heart and
decreases the force with which the heart contracts. This in turn reduces the oxygen needs
of the heart and thus helps in preventing the occurrence of angina. There are over a dozen
available beta blockers with similar activities. They have also shown to be benefit in
reducing the risk of a heart attack. Beta blockers are often avoided or used with great
caution in patient's with slow heart beat and obstructive lung disease (emphysema,
bronchitis and asthma). Fatigue, sleepiness, depression and decreased sexual libido may
be experienced by some patients. Some of these symptoms may improve by changing the
dose or type of beta blocker, or with the passage of time (weeks or months).

Calcium Channel Blockers: Calcium channel blockers decrease blood pressure and can
dilate coronary arteries. For these reasons, it is of value in the treatment of patient's with
angina; particularly in patients with high blood pressure or in those who have not
responded to a combination of nitrates and beta blockers.

Aspirin: Aspirin is one of the least expensive and most valuable medication in the
treatment of coronary artery disease. Platelets are small cells that float around in our
blood stream. They are the "beavers" of the body that rush to seal any break or breach in
the dam. When there is any type of damage or tear in the wall of a blood vessel, platelets
collect in that area, clump together and attract formation of a clot. This seals the damage
and stops bleeding when a person is injured.

Unfortunately, the same mechanism comes into play when the coronary artery develops
minor cracks in the inner lining of the coronary artery (plaque rupture). This can result in
a blood clot that seals the artery, cuts off blood supply to the heart muscle and leads to a
heart attack. Aspirin reduces the activity of platelets, decreases the tendency to form clots
and is thus extremely valuable in lowering the incidence of heart attacks in patients with
coronary artery disease. Aspirin should be avoided in patients with an allergy to the drug.
In such cases, alternative medications may be employed.

ngioplasty is used to widen arteries, which are narrowed by stenoses or occlusions. This procedure is helpful in many ways, like, clearing of plaque from coronary
arteries, emergency relief from a heart attackthat is in progress, and widening narrowed arteries in limbs, such as the femoral or iliac artery to the leg. It is also
useful in relieving chest pain, caused by narrowing down of coronary arteries. Angioplasty performed earlier was done by dilating the blood vessel with the
introduction of larger stiff catheters, through the narrowed space. However, complications involved in this procedure gave motive to scientists and researchers, to
develop a means of widening the vessel using a minimally sized device. Now lasers may be used to assist in the break up of fat or calcium plaque and catheters
may also be equipped with spinning wires or drill tips to clean out the plaque. The various types of angioplasty are as follows.

Balloon Angioplasty
Balloon angioplasty uses a thin tube, or catheter, which is passed into an artery, through a cut in the upper leg or the arm. The catheter is maneuvered into the
artery, and a balloon on the tip of the catheter is inflated. The balloon thus pushes against the plaque and flattens it, thus widening the artery. This improves the
flow of blood in the artery. It is normal for a patient to have pain in the chest, when the balloon is inserted. The movements of the catheter can be easily seen and
recorded by the doctors, on an X-ray screen. This helps in guiding the tube through the heart and into a narrowed coronary artery.

Laser Angioplasty
In the laser angioplasty technique, a thin and flexible plastic tube called a catheter, with a laser at its tip, is used. It is inserted into an artery that opens into
coronary arteries blocked by plaque, a build-up of cholesterol, cells and other fatty substances in an artery's inner lining. Then the plastic tube is advanced through
the artery to the blockage in the coronary artery, and it emits pulsating beams of light from where the laser is in position. These lasers help in vaporizing the
plaque. The laser technology can be used alone, or in combination with balloon angioplasty. If used along with balloon angioplasty, the balloon is inserted first to
attack the hard plaque.

Atherectomy
In case of atherectomy, special instruments are used to cut away the plaque. This technique is very useful in the treatment of blockages that may be too hard or
inaccessible for balloon angioplasty. People with plaque buildups in the carotid arteries are at higher risk for stroke. Atherectomy is an effective procedure that can
help patients by removing the plaque, which in turn reduces the risk of stroke. The different forms of atherectomy are:

• Extraction Atherectomy: In this procedure, a tiny rotating blade is used, which works in the almost the same way as a cutter on a food processor, to
cut away blockages.
• Rotational Atherectomy: In this procedure, a high-speed, diamond-tipped drill is used to penetrate the fatty deposits.

• Directional Atherectomy: In this procedure, a device that is a combination of a balloon and a shaving blade is used, to shave off the deposits.

Stenting
Stents were first approved in 1993, and since then, have gained widespread acceptance. They are small and expandable metal devices, which are inserted by a
catheter into a narrowed artery. This process is done after the angioplasty procedure is complete. Stents are left in place, in order to keep the artery from closing
again. They are generally used in combination with balloon angioplasty. It is possible that rarely a patient can develop blood clots, as a result of the use of stents.
This problem generally occurs in people with weak hearts.

Angioplasty is advantageous as the artery is returned to normal size without resorting to major surgery.

Drug-Eluting Stents
A new type of stent, the drug-eluting stent or DES, has recently become the overwhelming
choice of cardiologists. Two types are currently available in the in the United States: Boston
Scientific's TAXUS paclitaxel-eluting stent and the CYPHER sirolimus-eluting stent, made by
Johnson & Johnson / Cordis. Both stents are basically a bare metal stent that has been
coated with a slow-to-moderate-release drug formulation, embedded in a polymer. It is
hoped that the medicine used will prevent or at least reduce restenosis, reclosure of the
coronary artery, one of the biggest limitations of angioplasty and causes for repeat
procedures.

When the stent is placed, the drug is released over time directly to the area most likely to reblock. Two types
of drugs currently are being used: an immunosuppressive agent, sirolimus, and a chemotherapeutic drug,
paclitaxel. Both have proven effective in clinical trials that are currently underway, bringing the restenosis
rate from the 25-30% range down to low single digits. If the very positive results from these devices prove to
be durable over time, many have said that drug-eluting stents will revolutionize the treatment of coronary
artery disease. (For more information on drug-eluting stents,

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