Ops that could give your heart new life

When medication and lifestyle changes aren’t working, you may be offered one of two widely used procedures. Each is highly effective – provided it’s used for the right patients. Experts warn that patients need to understand exactly what each promises.

The first option is a percutaneous coronary intervention (PCI) – often called angioplasties. About 3,000 are performed every year in Ireland, making it the one of the most common cardiac procedures.

It’s designed to open up narrowed or blocked arteries and is carried out by ‘interventional’ cardiologists. It’s a keyhole procedure done through a small incision in the groin or arm and takes from 30 minutes to two hours. No anaesthetic is needed, though patients can be sedated.

A PCI involves a combination of treatments – angioplasty, where a tiny balloon is inserted to ‘squash’ the fatty deposits that have narrowed or blocked the artery, and the insertion of a stent, a short wire-mesh tube to hold the artery open.

Stents can be pure metal or ‘ drugeluting’, which means they slowly release a substance to prevent scar tissue growing into the artery and re-blocking it.

DRIP-FEED DRUGS IN YOUR ARTERIES

THESE drug-eluting stents (DES), introduced in the late Seventies, have had a bumpy history. Their use plummeted in 2006 when research showed there was a 1% risk of stent thrombosis, where a clot forms on the surface of the stent, potentially leading to a fatal heart attack.

However, second generation drug-eluting stents have largely solved the problem. But now there are concerns that too many PCIs are being done in appropriately. They account for four out of five interventions for heart disease.

When used as an emergency procedure following a heart attack or for people with unstable angina (sudden and severe chest pains), there is no doubt that PCI is the right course.

‘For them, it’s a life-saving procedure,’ says Dr Aseem Malhotra, a cardiologist at Croydon University Hospital, Surrey. ‘We know that for every 30 angioplasties carried out, one life is saved.’

However, about one in three PCIs is carried out on patients with stable angina and experts say the majority of these are a waste of time and money, as well as putting these patients at a small risk of internal bleeding, heart attack or stroke during the procedure.

Furthermore, for most patients with stable angina, a stent may be no better than medication at managing symptoms such as pain and breathlessness. And it won’t help prevent a heart attack, as numerous large trials carried out over the past 20 years have proved.

Despite this, ‘as many as 70% of patients undergoing non-emergency PCIs erroneously believe that the procedure is to improve life expectancy and prevent a heart attack’, says Professor David Taggart, of the Nuffield Department of Surgery in Oxford, the author of guidelines on stents published in the Annals of Cardiothoracic Surgery in 2013. He wrote: ‘Individual practitioners still follow personal preferences even though these are not evidence-based and may even be influenced by financial incentives.’

But that’s not to say a PCI is always inappropriate for people with stable angina.

‘It certainly has a place in managing unpleasant symptoms, especially when they interfere with everyday life,’ says Dr Malhotra.

‘But it’s important that patients offered a PCI for stable angina understand that neither a stent nor an angioplasty has any impact whatsoever in preventing a future heart attack.

‘The problem is that many patients don’t know this.’

REPLUMBING YOUR HEART

THE other form of procedure performed for heart disease is coronary artery bypass graft (CABG). About 2,000 are carried out in Ireland every year.

The operation is performed under general anaesthetic and takes up to six hours. It’s offered when all three major coronary arteries show signs of disease or when severe angina isn’t helped by medicine alone.

It involves taking sections of a vein from elsewhere – usually the chest, leg or arm – and attaching them to a coronary artery above and below narrowed areas or blockages, diverting blood around them.

For some patients there’s a choice between angioplasty and a CABG, says David Jenkins, a consultant cardiothoracic surgeon at Papworth Hospital in Cambridge and chair of the clinical audit group of the Society for Cardiothoracic Surgery. CABG is associated with better long-term symptom relief and a return to a normal life expectancy.

But the risks are slightly higher than for PCI, including bleeding, heart attack and stroke. Recovery time is 12 weeks compared with one or two for PCI. But with PCI, there’s a greater risk of symptoms recurring, and no rise in life expectancy.

‘We recommend that patients with coronary artery disease who do not fall clearly into one of the two types of intervention have their case discussed at a multidisciplinary meeting that includes cardiologists who do PCI and surgeons who do CABG, and that any recommendations are dis- cussed in detail with the patient,’ says Mr Jenkins.

TREATING A FAULTY HEARTBEAT

HEART disease is a major cause of heart rhythm problems (arrhythmias), such as atrial fibrillation, an irregular heartbeat. The heartbeat is determined by a small current that passes through the heart. A faulty heartbeat can trigger symptoms such as breathlessness, dizziness and fainting. It is treated with ablation, whereby a small wire – a catheter – is passed into a large vein in the leg and up into the chambers of the heart, where it is heated to create a scar to block the abnormal electrical circuits.