There is an ever increasing burden of cardiac cases being identified every day. An unfortunate scenario is the affliction of younger population and more unfortunate is the stress of the family and the patient goes through in this unexpected age group of patients. Though there is a steady increase of global burden of coronary artery disease or ischemic heart disease (heart attacks, unstable angina), it is the younger lot (age group between 30-45 years) being diagnosed with this aliment that is truly a big changing trend in the subcontinent and particularly India. When you break news of this deadly aliment to this unexpected age group, it is a big shock to the entire family. Apart from mental agony, it is also a big financial burden as many in this age group have just started earning their living and a big chunk of this population takes it easy and hence are not insured for their medical expenses. It has become very common to see fathers accompanying their sons (in this age group) to the hospital to seek cardiologist opinion, and when they enter hospital, it is wondering who the patient is.
In the elderly age group, there are also issues like family support, financial burden, physiological impact and pre-existing other medical co-morbidities (like diabetes, hypertension, degenerative diseases, prostate and other medical illnesses) which pose a big challenge to manage this age group patients.
Choosing between angioplasty and bypass surgery
Patients with angina chest pain caused by plaque built-up in the coronary arteries have a few choices of treatment. Though that choice may bring freedom, it can also bring confusion. Should you treat it with drugs, bypass surgery, angioplasty, or stents? A study published in the August 22, 2002 issue of the New England Journal of Medicine may help you and your physician start to make that decision. This study focuses on two treatments - minimally invasive bypass surgery and stenting.
Minimally invasive bypass surgery, a relatively new technique, involves a smaller incision than traditional bypass surgery. This offers the doctor limited access to the heart. As in traditional bypass surgery, the surgeon takes a blood vessel from another part of the patients body and either replaces the clogged artery with it, or uses it to reroute blood away from the blocked section, much like a detour reroutes traffic away from a blocked roadway. Using this technique, doctors don't need to stop a patient's heart as they do it in traditional bypass surgery. Stenting involves widening the narrow artery by temporarily inflating a tiny balloon in a blood vessel. The surgeon then places a circular wire mesh (stent) in the artery to flatten the plaque and hold the artery open.
In the study, researchers randomly assigned 220 heart disease patients to receive either the surgery or stenting. Doctors monitored the subjects following the procedures and saw them again six months later. Both treatments proved to be effective, but their success rates and longevity differed. Stenting was successful and without complication in all of the 110 patients who got it, whereas surgery was successful in 95% of the patients. Five of the 110 patients in the surgery group experienced complications during the procedure and a few required re-operation soon after their initial surgery.
While surgery had more early complications, its effects lasted longer than the effects of stenting. At six months, 79% of the patients in the surgery group were free from angina, compared to only 62% of patients in the stenting group. Narrowing of the arteries reoccurred in a large number of patients who received stents than those who underwent surgery. This caused 29 of the patients in the stenting group to require further intervention, compared to only five patients in the surgery group. After 2002, it has become common to use drug eluting stents (also called medicated stents) in high risk patients (diabetics and small vessels). There is enough data now which shows that use of drug eluting stents (even multiple stents) is equal or superior to bypass surgery as far as long term results are concerned.
The results of this study offer perspective on two of the available treatments for angina. Of course, when making this decision, doctor should also take into account of age, medical history, and the condition of coronary arteries of the patient.
Preparation for angioplasty and stenting procedures
1. Long term outcomes of angioplasty should always be discussed with the patient and their families. It should be made clear that in some cases, there may be need for repeat procedures so that it does not come as a surprise to them. Many patients are not aware of this and they feel a sense of discomfort and cheating when they discover later that they may need another procedure. This can happen due to restenosis (re blockage) in their stents in 10-15% of patients undergoing bare metal stent implantation and less than 5% of patients undergoing drug eluting stent implantation.
2. There is a false notion among the masses, that bypass surgery is a permanent remedy. They should be clearly told that a bypass surgery doesn't have a 100% event free survival rate, and 50% of grafts given (especially the venous grafts) are known to occlude within first 10 years of surgery.
3. The cost of angioplasty including one drug eluting stent or two bare metal stent is equal to bypass surgery. More number of stents makes angioplasty more expensive than bypass surgery.
4. Cost alone should not be a deterrent factor to avoid angioplasty. Age of the patient is very important. A patient less than 60 years of age should be pushed for angioplasty and bypass should be reserved for later age group as it is a one time surgery and should generally aim to see through the persons life span. Repeat bypass surgeries at advanced age tend to be high risk.
5. Technical details are important. If the vessel sizes are less than 2.75 mm, long lesion length or diabetics, drug eluting stents perform better than bare metal stents in these situations. Therefore, choosing a correct stent is not only important for long term results, but is as important to save the finances, as drug eluting stents are almost 2-3 times more expensive than bare metal stents.
6. It is also prudent to know the medical history of the patient. If a person has plans to undergo any elective non cardiac surgery (like prostate surgery, knee replacement surgery or any other planned surgeries) in the immediate future, then it is better to use bare metal stents or even consider bypass surgery (in high risk patients) and avoid drug eluting stents. Use of drug eluting stents requires a patient to take 2 oral blood thinners (namely aspirin and clopidogrel) for a long time, sometimes longer than 3 years, and it is difficult to operate the same patient for any major non cardiac surgery for there will be risk of bleeding if blood thinners are continued. On the other hand, if bare metal stents are used, one of these blood thinners can be stopped as early as 4-6 weeks and the other can also be temporarily be discontinued if need be without any risk of stent clogging (thrombosis) unlike in drug eluting stent.
7. Also if patient has peptic ulcer disease or severe gastritis or any other bleeding tendencies, long term use of two blood thinners is questionable, then again use of bare metal stents or bypass surgery should be considered.
It has become a fashion to use multiple drug eluting stents among the richer community. In my clinical practice, I advocate use of different types stents or need for bypass surgery depending entirely on the above scientific points that I have discussed. Whether one is rich or poor, it is always the science that wins the race. Unfortunately scientific decisions and economics doesn't go together. There will always be grey areas, where in it is prudent to give multiple options to the patient and the family and spend time to discuss with them. At times, taking a second opinion in these situations leaves a patient and family confused, therefore the need for them to be more educated about these procedures. It is easier to operate on educated people, doctor colleagues and their families and poorer people. This group listens to your logic and understands science better than the rich business but uneducated class who on many occasions end up messing up their decisions as they have a much narrower outlook.
Preparation for bypass surgery
Unlike angioplasty, bypass is a major surgery. Following are some of the concerns, thoughts, beliefs and burden that a patient goes through while preparing or awaiting for bypass surgery.
Can I get through it? Is there anyone who goes to surgery without a worry? It's normal for people to be afraid or to wonder if they are going to make it. Fears and doubts are common, and the patient should not feel odd if they have them.
It helps to share your feeling about heart surgery with someone who cares about you. Even if talking about it makes you a little anxious, it can bring out good feelings. It can make you and your family or friends feel closer. You may want to read what others have written about heart surgery or talk with others who have had it. All you need to remember is that each person's experience is different.
About heart surgery: One part of getting ready for heart surgery is to know about the surgery itself. All hospitals where bypass surgeries or other surgeries like valve operations are routinely performed, the hospital cardiac departments give brochures/booklets or pamphlets explaining the basic technical details of the surgery in simple language. All patients/family members should read this and can jot down queries if any and ask the concerned doctor or the attending nurse. Do not feel foolish for asking questions or saying what you are feeling. The more you know about what to expect, the easier your recovery will be.
Be kind to your body: If you have several days or weeks to get ready for heart surgery, this is the time to take very good care of yourself and plan to: Eat well, try to a variety of foods each day even if aren't hungry. It's important that your body gets enough vitamins and proteins. Eating well speeds healing, and you will be less tired after surgery.
Rest: Don't let yourself get too tired before surgery. The more rested you are the stronger your body will be. If visitors phone call tire you, just tell your friends that you need more rest at this time.
Exercise: walk or do whatever exercise your doctor has allowed. This helps relax your body and tone the muscles. It is less tiring to walk on flat surfaces at easy pace. Stop any exercise if you notice signs of your heart problem.
Smoking: Smoking is tough on the heart and lungs. It raises blood pressure, makes the heart beat faster, narrows the coronary arteries and smaller blood vessels and makes more mucus in the lungs.
Not smoking is one of the best things you can do for your body before any kind of major surgery. Stopping for even short time helps. You will breath better, and your heart won't have to work as hard.
It is really hard to quit smoking when you are anxious or under stress. Like before your surgery. You can follow some of the suggestions as below: Take it one day at a time. Ask family and friends not to smoke when with you. When you want to smoke, do something else with your hands. Go for a walk, get busy or do handiwork.
Learn to relax, plan time to be alone. Just sit and listen to the sound of your breathing. Read a book. Listen to music. Cut down on coffee, alcohol and other drinks that you are used to having with a smoke.
The Hospital - If you have been a patient before, you know some things about hospitals. If not, it may be very strange at first. It is not easy being a 'patient', but knowing these things can help you relax.
Before surgery - There are a lot of little things to be done to your body to get ready for surgery. These are routine for any surgical practice and will be well informed by the attending nurses, like cleaning and shaving the skin, preparation of bowels, preoperative medications, and orders regarding oral intake of food, liquids and fasting requirements.
Conclusion
It is not easy to prepare one self for any major procedure or surgery, especially when it is cardiac. Logical thinking, keeping calm and listening to you trusted cardiologist will easy your burden.
(The author is an interventional cardiologist, Dr L H Hiranandani Hospital, Powai, Mumbai)