Sunday, 24 July 2011

The Inevitability of Angioplasty

Published in Panorama


When Angioplasty became inevitable


It was 11:30 p.m and time for Mr. Mohd Zakir, 40 year old civil engineer, to retire to bed. All of a sudden he found himself feeling breathless. This was followed by some kind of uneasiness, heaviness in the chest. His brother drove him to a nearby clinic where an ECG was done and Zakir was asked to go to a hospital immediately. It was around 2:30 a.m when he was admitted to Welcare Hospital.

“All I remember was being wheeled in somewhere at Welcare. After that I completely blanked out till until some hours later when I was told I had suffered a massive heart attack and that the doctors there had indeed given me a second life with angioplasty! I was shocked because even when I went to the first clinic, I had not suspected a heart problem, least of all a heart attack! I had not had such breathlessness before and what happened that night was the first of its kind and so sudden at that!”

Electrocardiogram at Welcare confirmed a massive heart attack involving all the walls of the heart. A heart attack occurs when there is a clot in one or more of the arteries which supply blood to the heart, thus reducing the blood flow to that region of the heart, explains Dr.Rajesh Raipancholia, Specialist Interventional Cardiologist, Welcare Hospital, Dubai.

Zakir was transferred to the Intensive Care Unit where he was given clot buster medication to dissolve the clots. Because of the intensity of the blockages, the clot busters did not work to the desired extent. Despite all medications, his blood pressure continued to fall rapidly, the top pressure falling to 70 mm Hg. Since the heart was so weakened, there was rapid accumulation of fluid around both the lungs. He was unable to breathe on his own and had to be put on a ventilator.

Zakir’s echocardiogram showed heart pumping was only 35% of normal. He had to be given Inotropic medications to help the heart pumping. Since the clots did not clear with medication and his condition was causing concern, an emergency angiography was immediately performed. He was shifted from the ICU to the cardiac catheterization lab for the procedure. Dr.Raipancholia explains, “We had to put in a special mechanical device known as Intra Aortic Balloon Pump (IAB) to support the heart while we did the angiography. This is not normally done, except in higher risk patients, especially in patients who have low heart function. While angiography as an elective procedure is a very safe one, in a patient who is on ventilatory support, has low blood pressure and who is on inotropic support, angiography itself carries a risk.”

Angiography showed that there was 70% block or narrowing in Zakir’s Left Main Coronary Artery (LMCA). The left anterior descending branch of this main artery was also blocked 90% and the right coronary artery had a 99% blockage. Dr.Raipancholia reveals, “Such a patient would have been an ideal candidate for a Coronary Bypass Surgery under normal circumstances, but Zakir’s condition was far too serious to allow us to do that! Imagine, if there is a block in the LMCA just before it divides into the two branches. Doing angioplasty here would mean putting a balloon or stent across which would momentarily reduce the blood supply to the whole of the heart! So these patients are normally advised bypass surgery. In Zakir’s case, he was so critically ill, that bypass surgery would have been a greater risk.”

Emergency angioplasty and stenting was done, initially in the LMCA, and also in other two arteries using medicated stents. Zakir was shifted back to the ICU and within 24 hours his condition was gradually improving. Ventilatory and IABP supports were taken off and he was slowly taken off the intravenous medications that were used to support the heart. A repeat echo cardiogram confirmed improvement in the heart function to around 50%. He recovered very well and was discharged from the hospital in eight days.

Says a relieved and grateful Zakir, “I am on medication but I am back to work now, one month following the angioplasty. But the work that I’m doing now is not strenuous – it’s office work at the desk. Else my job actually requires me to be on my feet for long hours, visiting the construction sites and being there for quite a while, with long walking distances as well. Upon the doctor’s letter I’ve now been assigned a desk job and I think it will be like that for some time. Of course, I’m feeling much better but yes, sometimes when I walk a little too much, I do feel a little short of breath. Dr.Raipancholia has seen me twice in the course of this one month as part of the follow up. And for my part, I’ve quit smoking and am following a strict diet with very little fat content in it and am doing light exercises.”

Most of today’s maladies are triggered by stress as one of the contributing factors. Smoking and ischemic heart disease in his mother, coupled with his stressful job have probably played villain in Zakir’s heart attack at his age. Dr.Raipancholia reveals, “LMCA narrowing is found only in about 5% of patients undergoing coronary angiography. Until recently it had been regarded as an absolute indication to do coronary bypass surgery. But with newer generation of medicated stents and latest medications angioplasty/stenting can be performed in selected patients with this problem. In Zakir’s case, his life was saved because the procedure allows prompt restoration (within half an hour) of blood flow to the heart before extensive and irreversible damage could set in to the heart muscle.”

Is it possible for patients to come down with such massive attacks without any prior warning signals? Dr.Raipancholia reveals, “Yes, this can happen to anyone. In Zakir’s case, fortunately he arrived quickly. Unfortunately, this was his first presentation and that too directly with a heart attack, without any symptoms like chest pain or breathlessness on exertion. But when he came to Welcare Hospital, his symptoms were typical of a heart attack.”

What is the prognosis in Zakir’s case and others who may manifest similar problems and undergo similar procedure? According to Dr.Raipancholia, Zakir would be on medication initially to keep the stents patent or open. He will also be on aspirin life long and on another blood thinner for one year. He is expected to do well though he would be expected to be on medication to lower the cholesterol level, follow good diet and exercise regularly.

What are the chances of re-narrowing of the arteries? Dr.Raipancholia comments, “Yes, you can have narrowings within the stents themselves and that’s precisely why we now have these newer, medicated stents. Balloon angioplasty had a re-narrowing rate of 35% - 40%. Then came the ordinary stents which lowered the re-narrowing risk to about 17% - 20%. The medicated stents have brought down re-narrowing risk to between 3% and 5%. The re-narrowing risk is more pronounced in diabetics. The chance of re-narrowing depends on a few factors: the patient’s profile – greater the number of risk factors, greater the risk of re-narrowing, the type of narrowing or lesions the patient has, greater the length of lesion, higher the risk of re-narrowing, smaller vessels, in terms of width, have a higher re-narrowing rate. In a person who has had previous re-narrowing, if you do another angioplasty at the same site, the risk of re-narrowing is higher.”

Dr.Raipancholia adds a word of caution: “No matter the procedures to tackle the problem, it is more important that we try to prevent the problems from happening at all in the first place. Leading a healthy lifestyle, following a good diet and exercise regime & not smoking would prevent us from having all these expensive tests and treatments.”



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