Heart disease: Which treatment option is right for you?

Many people find out they have coronary artery disease (CAD) when they experience chest pain called angina or have a heart attack. There are three treatment options for CAD: medical treatment, coronary angioplasty and coronary artery bypass graft surgery. How do doctors decide which treatment option to use?

CAD is due to a build-up of plaque inside the coronary artery. The plaque narrows the artery and eventually impacts the blood supply to the heart. It can present in two ways with very different prognosis and treatment:

1. Stable angina, where patients only get symptoms on exertion.
2. Acute coronary syndrome, where symptoms occur even at rest, resulting in a heart attack.

“All patients with CAD should receive baseline medical treatment, which consists of medication and lifestyle modifications that aim to control symptoms and risk factors,” says Dr Aaron Wong, Head and Senior Consultant, Department of Cardiology, National Heart Centre Singapore (NHCS), a member of the SingHealth Group.

Medication can include aspirin and statins, which have been found to reduce the incidence of heart attack and death. Diabetes, high blood pressure and high cholesterol are important risk factors that need to be addressed.

“If symptoms are not well controlled with medication, or in the case of certain high-risk patients such as those with acute coronary syndrome, we can consider coronary angioplasty or a coronary bypass,” adds Dr Wong.

Related article: Is your chest pain harmless or a sign of something more serious?

What is coronary angioplasty (percutaneous coronary intervention or PCI)?

Coronary angioplasty, also known as percutaneous coronary intervention or PCI, involves threading a thin tube into the clogged artery through a blood vessel in the leg, arm or wrist. A tiny balloon is then inflated to force the blocked artery open, allowing blood to flow through it. A stent, or mesh tube, is placed in the artery to keep it open. The procedure is performed under local anaesthesia.

PCI is associated with a relatively lower risk and faster recovery than coronary bypass surgery, an open heart surgery. However, the artery can narrow again despite the stent.

What is coronary artery bypass grafting (CABG)?

Coronary bypass, also known as coronary artery bypass grafting or CABG, is an open heart surgery. In this procedure, the surgeon removes a vein from the leg or chest and sews it beyond the blockage so that blood can flow through the newly grafted vessel, bypassing the clogged coronary artery.

CABG results are more durable. They last an average of 10 years. However, coronary bypass has a slightly higher risk for complications than angioplasty. It also requires a longer hospital stay (one week) and longer recovery (one to two months).

Related article: Eating even one Western fast food a week could significantly increase your risk of dying from heart disease

Which is the preferred intervention?

For stable angina or stable CAD:

“Once it has been decided that re-establishing blood flow to the heart is appropriate, the choice between PCI or CABG remains complex in patients with stable CAD,” says Dr Wong.

Beyond the general pros and cons of each procedure described above, at least three important factors need to be considered: the complexity of the CAD, the diabetic status and heart function.

It is important to know that PCI (angioplasty) has not been shown to improve survival or prevent a heart attack in patients with stable CAD. However, it can be considered for symptom relief.

For acute coronary syndrome:

“In patients having a full heart attack, immediate opening of the blocked artery is recommended within 90 minutes to save the heart muscle and, in some cases, the patient’s life. In this case, PCI can be done much faster and is safer than CABG,” says Dr Wong.

When angioplasty is not possible or too dangerous for anatomic reasons, coronary bypass surgery or CABG may be preferred.

If CABG is preferred, it will usually be performed after a few days or weeks, once the patient has been stabilised with medication.

Related article: How can you survive a heart attack when you’re alone?

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By Teresa Cheong for HealthXchange.com.sg.

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