Pill / Medications
Various drugs can be used to treat coronary artery disease, including:
- Cholesterol-modifying medications. These medications reduce (or modify) cholesterol plaques, which are the primary material that deposit on the coronary arteries. As a result, cholesterol levels — especially low-density lipoprotein (LDL, or the “bad”) cholesterol — decrease. Your doctor can choose from a range of medications, including statins, fibrates, bile acid sequestrants and newer drug agents such as PCSK-9 inhibitiors.
- Aspirin. Your doctor may recommend taking a daily aspirin (or an alternative blood thinner) to reduce your heart attack risk. Aspirin can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries. If you’ve suffered a heart attack, aspirin can help prevent future attacks. However longterm use of aspirin maybe associated with increased risk of bleeding and gastric ulcers.
- Beta blockers. These drugs slow your heart rate and decrease your blood pressure, which decreases your heart’s demand for oxygen. If you’ve had a heart attack, beta blockers reduce the risk of future attacks.
- Calcium channel blockers. These drugs are vasodilators, hence they dilate and improve blood flow to the heart. They can therefore be used to treat chest pains or angina. They are also useful to reduce blood pressure.
- Ranolazine. These drugs are vasodilators, hence they dilate and improve blood flow to the heart. They can therefore be used to treat chest pains or angina. They are also useful to reduce blood pressure.
- Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by temporarily dilating your coronary arteries and reducing your heart’s demand for blood.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). These similar classes of drugs are useful in heart failure. They also decrease blood pressure and may help prevent progression of coronary artery disease.
Coronary Angioplasty and Stenting
A coronary angioplasty is a minimally invasive procedure used to widen blocked or narrowed coronary arteries (the main blood vessels supplying the heart). The procedure is often done, under local anaesthesia, through a small incision either in the wrist (radial artery) or groin (femoral artery), where a small balloon catheter is advanced to the heart under x-ray guidance. The balloon is placed where the blockage is, and then inflated to open up the narrowing. Sometimes multiple inflations maybe required to achieve a good result. The balloon is then removed once flow down the coronary artery has been established. A metallic scaffolding called a “stent” is then inserted. There are many types of stents currently available, the most common stents used in Malaysia currently are the “drug-eluting stents” which are metallic stents coated with medications to reduce the likelihood of future re-narrowings or recurrences. The latest generations of drug-eluting stents are effective in keeping the vessels patent, and are associated with very low risks of stent thrombosis (clotting of stents <0.3%), and in stent restenosis (renarrowing of stents <5%).
Coronary angioplasty and stenting has been shown to be highly effective in improving symptoms, reducing chest pains and increasing exercise tolerance post-procedure. During a heart attack, immediate coronary angioplasty can increase your chances of surviving. The procedure can also reduce your chances of having another heart attack in the future.
CABG bypass surgery
A coronary artery bypass graft (CABG) is a major surgical procedure used to treat severe coronary heart disease. It is done by opening up the chest wall and inserting “bypass grafts”, which are new blood vessels to overcome the existing blockages in the original vessels. Grafts are conduit created from veins from the legs or arteries behind the chest wall, to divert blood around narrowed or clogged parts of the coronary arteries to improve blood flow and oxygen supply to the heart.
A CABG operation often takes three to six hours to complete. It’s done under general anesthesia, to ensure that the patient is asleep and pain free through the whole surgery. The chest wall is opened up through an 8- to 10-inch cut to expose the heart. Once the heart is visible, the patient may be connected to a heart-lung bypass machine. The machine moves blood away from the heart so that the surgeon can operate. Some newer procedures (off –pump) do not use this machine. The surgeon uses a healthy vein or artery (from the leg or behind the chest wall) to make a new path/ conduit around the blocked artery.
Coronary Angioplasty vs Bypass – Which is better?
Both procedures are aimed at improving the flow of oxygen-rich blood to the heart.
Angioplasty is a minimally invasive method of widening a coronary artery (see above). It is done under local anaesthesia only (although the patient may be offered sedation), and patients maybe discharged home the same day or the next day. The procedure is also relatively safe, and complication rates are low. The most common complications of angioplasty are minor such as bleeding, haematoma, contrast allergy etc. The risks of major complications such as heart attacks and strokes are extremely low (<0.5%). The recovery time for angioplasty is also quick, as patients are often discharged within 24hrs, and may resume their normal activities within a few days.
Comparatively coronary heart bypass (CABG) is major surgery, where the patient will be hospitalized for about 1 week (1-2 days in ICU, followed by rehabilitation in a General ward for the following 4-5 days). It may take 2-3 months for full recovery. The immediate risks with major CABG are often higher compared to angioplasty, and include the risks of strokes (1%), bleeding, chest wound infections (more common in patients with obesity or diabetes, or those who’ve had a CABG before), heart attacks, irregular heartbeats, lung or kidney failure and pneumonia. The complication rates are higher in the elderly, and those with concomitant co-morbidities (such as previous stroke, kidney or lung disease). CABG does however provide more complete revascularization in patients with very diffuse disease where it is not possible to carry out coronary angioplasty. Hence the decision of whether CABG or angioplasty is better will depend on many factors, and every patient will need to be assessed individually by the cardiologist or Heart Team before a decision is made.
