CHENNAI: It is well recognised that chronic stable coronary artery disease is one of the most benign of the maladies man weathers. A significant number of people are affected, many are asymptomatic or minimally symptomatic, some have significant symptoms contained by lifestyle modification and medications, and a few have limiting symptoms. But all of them have a chronic disease, and three to six months after its onset, the intensity of the symptoms remains largely stable.
Revascularisation (read angioplasty here) is not particularly useful in this subset of patients and it could possibly do harm. In the studies where the hypothesis was tested, however, patients with high-risk substrates like left main coronary artery disease, triple vessel disease with proximal LAD disease and two-vessel disease with proximal LAD disease where revascularization has mortality benefit were not separately studied.
The landmark Courage trial, published some 10 years ago, where revascularization was ischaemia guided, reaffirmed this fact and it led to quite a lot of changes in the way interventional cardiology is practiced worldwide.
The recent Orbita trial has stirred a lot of interest in this regard, especially among the public, thanks to social media where study results were widely shared. Why I decided to write this is for the same reason. A lot of confusion is created about the very purpose of angioplasty and stenting. It was painted as mostly unnecessary, wasteful and done with ulterior motives of the doctor. What is the reality?
Angioplasty is known to benefit in terms of morbidity and mortality when done in patients with acute myocardial infarction and unstable coronary syndromes. It is also beneficial in patients having limiting symptoms despite optimal medical therapy where a physically demanding lifestyle is warranted.
Angioplasty has proven useful in patients who have recurrent angina post bypass surgery for symptom relief, in patients who are not good candidates for bypass surgery when anatomy is suitable for the procedure and for patients who refuse bypass surgery. Many patients who are candidates for bypass will also benefit from angioplasty with new generation stents if anatomy is suitable. There is no difference in mortality, provided they are willing to undergo repeat procedures if symptoms recur, including patients with Left Main coronary disease.
So what is the confusion? It is clear that chronic stable coronary artery disease doesn't call for angioplasty, so also a bypass surgery. There are no second thoughts about it.
However, limiting symptoms despite optimal medical therapy where an active lifestyle can't be pursued calls for one. In Orbita study, where 200 patients were randomized to angioplasty versus a sham procedure (angioplasty was not done), there was no difference in exercise duration at the end of six weeks between the two groups. Majority of the patients had proximal LAD disease.
All patients had six weeks of medical therapy where medications were optimised prior to intervention. This could have led to better exercise
tolerance in the sham group, too. Patients in the angioplasty group numerically had better exercise duration and dukes score, though statistically not significant. The study was well done and powered enough to assess exercise capacity but not other hard-end points like death or myocardial infarction. If follow up was further extended, these differences might widen but it is just anyone's guess.
Angioplasty and stenting are here to stay. Chronic stable coronary artery disease doesn't call for angioplasty. I understand that the number of procedures done in such cases is very few world over, after the Courage trial results some 10 years ago, except in select cases as mentioned earlier. In acute ST elevation myocardial infarction it stands tall as the treatment of choice if it can be performed within 90 minutes.
Angioplasty is not just pushing stents as being portrayed. It saves life and benefits patients. It has stood the test of time.
Ask the doctor
A couple of months ago when my wife (76) was admitted with complaints of vomiting, at a city-based hospital, the chief cardiologist, viewing her ECG said that ‘many heartbeats are missing’. Since the blood pressure was found to be higher — 170/100 — especially during evening, he added new medicines to the existing list of drugs already being taken (telma40, Corbis 2.5, nitrocontin 2.6) silaheart 5 mg too.
She has been a bronchial asthmatic for well over 50 years and has been using salbutamol inhaler alone. In addition, OCD exists for nearly 12 years for which she is taking paroxetine escitalopram rivotril opiprol 50. I would like to know whether the missing beats are indeed AF? Will it propel any emergency? She walks two to three km daily, keeps up her routine on her own.
S Suryanarayanan
Missed beats are a layman’s term used when there are actually ectopic beats. These are additional heart beats arising from locations of heart in atria (upper chambers) or in ventricles (lower chambers). It is very common and is usually without much of consequences, if there is no structural heart disease. Anxiety is a common situation when this occurs in an otherwise normal heart. Thyroid disease is another very common condition. In the presence of lung disease, ectopic beats frequently originate from atria. Often, it doesn’t need treatment as such. Corbis is Bisoprolol, a cardioselective betablocker that is effective in reducing ectopic beats.
Higher antiarrhythmic therapy is usually not needed in this condition. However, if the situation is so called atrial fibrillation, or if it ensues, anticoagulation (blood thinner in common man’s term) may be required. Usually ‘missed beats’ do not lead to medical emergencies. However, if atrial fibrillation occurs, it can lead to palpitations and at times lowering of blood pressure and breathlessness. Frequent ectopic beats arising from the ventricles need medical attention. It may need betablockers as mentioned and rarely anti arrhythmic drugs if it leads to more malignant arrhythmias. Since the doctor has prescribed only low dose of betablocker, it is reasonable to assume ectopic beats may be infrequent and further evaluation may not be warranted.
I am 73 years old. Last month, I suddenly experienced chest pain on the left and right sides, centre and a little below. My jaws were also hurting. The chest pain was unbearable and I felt quite uneasy. As per my family doctor’s consultation, I took an ECG, which showed normal reports. The doctor advised a blood test called protonin, and again, the results were negative. The doctor prescribed some medicines to ease the pain. As my heart function is normal and the blood test results were also normal and the blood test results were also normal, why is the chest pain occurring? I wish to mention here that my BP was 120/80 and my pulse 82/mt. I felt the chest pain recurring twice recently, even after treatment.
TK Panduranga Rao
Your descriptions suggests it is cardiac pain. ECG will be abnormal mostly during pain, unless it has led to heart muscle injury. Once the pain subsides, the ECG tends to be normal in same scenario. Troponin also will not be positive unless cardiac myocyte damage occurs. It may be appropriate to do a cardiac stress test. Treadmill test is the best. If you can’t walk on treadmill, a nuclear perfusion study can be done or take a dobutamine stress echo test.