Leaping ahead of the Western countries, India has now emerged to be the world capital of heart diseases. By the end of 2010, 60% of the world’s heart patients will be inhabitants of India.

The sedentary life style fused with unethical food practices of the hi-tech savvy generation has worstly affected the ‘pride possession’ of a healthy heart for the young and older generations alike. Heart attacks or Myocardial Infraction (as precisely called by medical professionals) was earlier a monopoly of the sexagenarians.  But now 50% of cardiovascular deaths in people aged below 50 testifies the vulnerability of young lots to this dreadful malady.

What is angioplasty

The word Angioplasty is made combining the Greek words aggeios  (meaning vessel) and plastos (meaning formed)

Angioplasty is a procedure in which a balloon catheter (thin tube) is inserted into a blocked artery to remove the blockage. The blockage may be in an artery in the arm, leg, or in the heart.  Angioplasty along with use of a medicated stent is called medicated angioplasty, which carries a long term success rate of more than 95%.

What happens during the procedure?
The procedure is carried out under a local anesthetic. A catheter    (a fine hollow tube) is inserted into an artery in either the groin or the arm. Then, with the aid of X-Ray screening, the surgeon directs the catheter to the coronary artery until its tip reaches the narrowed part of the blood vessel. A sausage – shaped balloon (hence this procedure is also known as balloon angioplasty) mounted on the tip of the catheter is gently inflated which flattens the atheroma causing the blockage in the blood flow. After one or two minutes the balloon is deflated and removed. An enlarged channel remains facilitating easy blood flow to the heart. A stent is a short tube of stainless steel mesh which is inserted at the part of the affected artery. The catheter after being inflated, the stent is slightly expanded to hold open the narrowed blood vessel and is left in the place where the instrument has been removed. The stent keeps the vessel opened. It can also reduce the risk of complete blockage of coronary artery that can happen occasionally. Antiplatelet drugs are administered around the time of angioplasty to reduce clot formation encircling the new stent.

What happens after the procedure?

Post – angioplasty requirements include complete bed – rest in a  coronary care unit for one day and another day in the hospital.

What are the benefits of angioplasty?

It can restore the function of the artery without major surgery.

It does not require removing blood vessels from another part of the body (as is often necessary in bypass surgery).

It can be performed without using general anaesthesia.

What are the risks associated with this procedure?

This is a relatively safe and painless  procedure and not too many risks are involved. In any case, the expected benefit far outweighs the risks Ninety nine out of every hundred Angioplasty procedures are successful which proves the reliability of the method involved. Emergency surgery is warranted only in  1 out of 100 -500 cases.

Medicated stents
The most recent trend in stent technology is the use of medicated stents. Stainless steel and cobalt chromium stents are coated with rapamycin so that stent blockages will not occur in the future.

ANGIOPLASTY AS TREATMENT FOR HEART ATTACK(PAMI)
Time is Life: Extensive research has shown that the outlook for patients having a heart attack is closely related to the length of time the artery remains blocked; the longer the duration of the blockage the higher the death rate and morbidity that results. The risk of sudden death is almost 20% in the first 24 hours with 50% of these occurring within the first hour of heart attack. Re-establishing blood flow as quickly as possible remains the most important principle underlying treatment. Thrombolysis and primary angioplasty are the two principal methods proven to re-establish blood flow. The outcome for those who survive is largely determined by the extent and severity of the residual damage after treatment. Angioplasty is now regarded as the “gold standard” for treating  heart attacks, needless to say the miraculous success rate of the procedure. Even though the technique was devised in the late seventies, it is only during the past fifteen years that it has been primarily prioritised in the heart attack treatment module.
Primary angioplasty is a term used to describe an angioplasty done as a life-saving emergency procedure in a patient with an on-going heart attack (PAMI or Primary Angioplasty in acute Myocardial Infarction). Heart attacks occur due to sudden total occlusion of a pre-existing partial block, thereby completely cutting off the blood supply to a portion of a heart muscle. These 100 per cent blockages need to be removed within three to six hours from the onset of heart attack, else the muscle of the heart gets damaged permanently. Doing angioplasty in a critical patient of heart attack is in itself challenging and doing so in the critical window period of three to six hours further adds to the challenge. The treatment of a heart attack is not just saving the  life of the patient , it involves saving the heart with as minimal damage as possible.
Success rate of primary angioplasty is more than 95 per cent when performed in experienced hands. That means death due to heart attacks can be reduced to less than 5% if angioplasty can be performed within 3- 6 hours after the onset of chest pain. At times especially during night it is very exhausting  physically, though mentally it is extremely rewarding. PAMI is one of the most miraculous medical procedures, with incredible gratification for the doctor.The thankful smile on the patients and his familys face the next day is the biggest reward  we cardiologists get.  The author had the opportunity to perform the first primary angioplasty in the State in 1997.

MEDICATED ANGIOPLASTY VS BYPASS SURGERY

Angioplasty is done by the cardiologist and bypass surgery by the cardiac surgeon.Angioplasty aims to open narrowed or blocked arteries where as bypass surgery tries to bypass it. Coronary interventions like angioplasties have almost come to replace coronary artery graft bypass surgeries as it can give equivalent results as the latter (bypass surgeries). The concept that angioplasties will give only temporary relief and that bypass surgeries offer the best permanent outcome has become obsolete with the arrival of medicated stents and new technologies. Today, very complex coronary angioplasties  are successfully performed by  experienced doctors with excellent long-term results.

The  total length of incision for angioplasty is 1mm,whereas for bypass it is close to one metre. (chest, hands and legs put together).The third major difference is the duration of rest after the procedure.angioplasty needs rest only for 2 days wheas bypass needs rest for 2 months.The most important difference which the patients perceive is the near absence of pain for angioplasty procedure.

The facts that the procedure does not require a major incision, the patients need not be under general anesthesia and the minimal rate of complications have shooted the popularity of angioplasty. Moreover, most patients can be at home the very next day or two after angioplasty.

The latest generation of medicated stents come with a biodegradable polymer  so that blood thinning medications can be temporarily discontinued after 3 -6 months for any surgical procedure.But this should be done only in consultation with the treating doctor.

WHO NEEDS BYPASS SURGERY ?

In the authors  personal experience of over 13 years in performing angioplasty,most cases which were send for bypass surgery few years ago are now very successfully treated with medicated stent angioplasty.But bypass surgery is still required in some extreme cases or when concomitant valve or other surgery has to be performed. In countries like japan bypass surgery is very rarely performed.

WHO DOES NOT NEED ANGIOPLASTY ?

When the narrowing in the artery is less than 70%, angioplasty is definitely not required. Most critical blockages can be managed with medicines alone.Angioplasty is required only when medications are insufficient and when enough natural collaterals have not formed.

Moreover there are more than 400 causes of chest pain and above the age of 60 more than 10% of the general population has some degree of blockages in the coronary arteries. Also minor unimportant ECG changes can be present in a good percentage of normal people (normal variant)Improper evaluvation of chest symptoms and cardiac investigations  can lead to unnecessary angioplastiesand bypass surgeries.The author has personally seen many patients who have undergone angioplasty or bypass for gall bladder disease or peptic ulcer disease or musculoskeletal problems or even vitamin deficiencies,all of which can produce chest pain and ECG changes.

Angioplasty clears only the blockages in the arteries and not the causes of the blocks. So patients need to continue lifestyle modification and  low dose medications  indefinitely.

The only sarcastic progress is in the demographic shift to the lower class of people, who were once inaccessible to heart ailments. The wider availability of rich food and the advent of mass transportation modes shall be accredited to the paradox.  But a ray of hope lights our heart that cardiovascular risks can be reduced with lifestyle modifications which include lighter eating, balanced diets, regular exercise, quitting tobacco etc. and sometimes very small doses of the statins and aspirin in selected cases. Remember, not only prevention is always better than cure, sometimes it can be life –saving also ,and definitely cheaper.

DR.SAJY KURUTTUKULAM
CHIEF CARDIOLOGIST
MEDICAL TRUST HOSPITAL
KOCHI
drsajy@yahoo.com