Ask Dr Nandakumar: Heart Stents

Yes, coronary artery disease can be treated with lifestyle changes - exercise along with diet/stopping smoking/losing weight and reducing stress. However in certain kinds of coronary disease (may need both a coronary angiogram and nuclear scan) where there is a severe blockage which is causing impairment of blood flow to a significant part of the heart muscle, it maybe advisable to proceed with heart stent or bypass surgery to prevent a heart attack with poor outcomes including mortality.

I am afraid the evidence does point to the fact that there is a clear advantage both in terms of quality of life and mortality benefit (for instance in those patients who have a narrowing of more than 50% in the left main stem ie the major branch on the left side of the heart, only 50% will survive beyond three years on medical treatment alone). Of course mild to moderate narrowing in a small noncritical vessel will neither confer a survival advantage nor cause a dramatic change in your quality of life.

There are essentially 3 treatments for blocked heart vessels – ie Medical therapy Angioplasty or stents, and Bypass surgery However which of these options is most suitable for yourself depends on the presence of the blockages, their severity and location. In addition other factors such as Diabetes, high blood pressure and high cholesterol also play a part. It is important that lifestyle changes always accompany all of the above three options. Medical therapy is usually recommended when there are mild fatty thickening in the arteries.

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.

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.