Dr Nandakumar Ramasami

Well done indeed! Stopping smoking is the best gift you have given yourself and your family this New Year! You probably feel a better sense of smell and taste. By now more oxygen is reaching your heart and muscles easily and your immune function and circulation are getting better. However it will still be a while before risk of heart disease drops significantly (up to 2 to 5 years) and will take longer (up to 10 to 15 years) to approach that of a non-smoker.

Recovery time after an angioplasty is pretty similar in most parts of the globe. In terms of recovery we generally aim for a 4 to 6 week period to get back to full activity. Usually the cardiac rehabilitation team will come to meet you if you have been admitted with a heart attack and following the angioplasty procedure they will provide guidance on the do’s and dont’s.

The coronary angiogram is the current gold standard to establish the degree of coronary artery disease and with experience one can usually determine the stenosis with just “eyeballing”. However, I do use adjunct imaging inside the blood vessel itself, and this helps to clearly establish the area and character of the narrowing or stenosis in the coronary vessel. Evidence from trials clearly show that a narrowing is critical when it approaches 70% as it affects blood flow to the heart muscle.

In general the number of heart bypass surgeries has been falling globally as heart angioplasty (heart stent) technology has improved in leaps and bounds especially over the last decade. Surgical techniques have also improved and newer techniques such as off-pump bypass or MIDCAB are available. However, the reason why angioplasties are more popular are because of the quick recovery and absence of the need for open surgery though there maybe a need for repeat procedures.

If it is indeed mild mitral regurgitation/mild mitral valve prolapse with no symptoms at all international guidelines mandate no more than an echocardiography test every 3-5 years. You should otherwise lead a full & normal active life. If you do have palpitations a Holter test is recommended. Other symptoms might have a bearing on the frequency of echocardiography and also the need for other investigations or treatment. However, no specific treatment is recommended if there are no symptoms. General advice such as ensuring good oral health with dental review every 6 months is recommended.

Yes we do use devices occasionally to remove/shave/excise plaques but this is used in less than 5% of coronary angioplasties at present. The current devices licensed for plaque removal usage in the heart are called: Rotablator (a nickel plated brass burr with microscopic diamond crystals on it rotating at high speed) which excises the hard plaque tissue Excimer laser (which uses high energy light to dissolve plaque without harming healthy tissue) and Orbital atherectomy (which uses a diamond coated crown rotating at high speed to kind of “sand ” the calcium away).

A heart stent should and will last for life. A stent after all, is a wire-mesh scaffold and functions as such. Once a stent has been placed the inner vessel wall (called endothelium) slowly grows over it until it “heals”. Drug-coated stents ensure that this healing is not too excessive as in the days gone past, this excessive healing would lead to re-narrowing. This healing takes between 3 to 6 months and that is why you need blood thinning agents to keep your blood thin as the stent heals. If not, the stent being a foreign body the blood going past it will clot instantaneously.

Both angiogram and angioplasty procedures are quite safe in this day and age. But any invasive procedure does carry a small risk. Some of the major risks of the procedure would be risk of heart attack (0. 05%), stroke (0. 07%), need for emergency cardiac surgery (0. 05 to 0. 3%) and mortality (0. 08 to 0. 65%). Bleeding and damage to the artery where we access is between 0. 2 to 1%.

It depends on whether the patient falls in the low, intermediate or high risk category based on: The severity of the narrowing (we use scores such as modified Duke Score/SYNTAX score etc ) Heart’s pumping ability( by echocardiography) and Presence of other issues such as blood pressure, diabetes and high cholesterol It also depends on whether patient is stable and the procedure is an elective procedure, or if the patient has presented suddenly with chest pain or breathlessness which drastically alters the strategy.

When deciding between medical therapy, heart stents (angioplasty) or cardiac bypass surgery, I take into account the full picture based on factors such as: Clinical presentation Patients age Mental and neurologic status Location and severity of the blockages Symptoms Ability to take long-term blood thinning tablets and Other issues such as diabetes, kidney function and heart failure along with patient expectations and preferences. I also use validated specific “scores” to help decide the strategy such as “Syntax” score.

Well the term “stent failure” usually indicates either that renarrowing has occurred or that it has been blocked completely. Complete blockage can be sudden and obviously causes chest pain, breathlessness or sweating, chest discomfort and may include all the features of a heart attack. Re-narrowing on the other hand, usually occurs slowly over time and is marked by return of symptoms such as chest pain or breathlessness on walking. In fact, any of the symptoms you had before the heart stent was inserted can return.

Yes indeed, CT coronary angiogram (CTCA) and cardiac MRI are non-invasive but are not as accurate as a “normal” angiogram though the sensitivity can be as high as 96%. Current guidelines generally recommend using a CTCA when there are: Symptoms (chest pain, palpitations, discomfort or breathlessness on exertion) Inconclusive or normal stress tests with ongoing symptoms and a Low to intermediate probability of coronary disease (ie narrowing or blockages).

A coronary angiogram is performed whenever a patient has symptoms such as breathlessness or chest pain on exertion (not always) which usually indicate poor blood flow in the heart blood vessel due to blockages. This could a non-invasive angiogram (ie CT coronary angiogram) or an invasive coronary angiogram (gold standard test). The modality depends on the risk and if the risk is higher an Invasive coronary angiogram maybe warranted.

Let me give you a very brief overview of the development in the history of stents before coming to the practical aspects. In the 1960’s Dr Dotter described the conceptual aspect of angioplasty ie using a device like a catheter to dilate a narrowed artery. Dr Andreas Gruntzig in 1977 performed the first angioplasty procedure in an awake patient and in 1986, the first human coronary stent was inserted in France.