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Suffered a heart attack. Cardiologist advised to undergo angioplasty. Is it necessary? What are the side effects?

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Cardiologist, Interventional
Practicing since : 1996
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My dad recently suffered a heart attack.He was in the ICU for 4 days & finally discharged with stable haemodynamics after a week of hospitalization.The hospital discharge report states that he has the following conditions:
1. From ECG: IHD-Acute anterior wall MI(lysed outside).
2. From 2D-Echo: Ischemic heart disease, LV segmental hypokinesia, Reduced LV function-EF 45%, No obvious clot.
3. From Coronary Angiogram: Single Vessel Coronory Artery Disease - 80% LAD Lesion.
4. Known case of diabetes mellitus newly onset.

After Coronary Angiogram, the cardiologist advised that he undergo Angioplasty & stent implantation to LAD artery. We got him discharged as we wanted a 2nd opinion & did not want to rush Angioplasty.

1. Is Angioplasty a must or can his condition improve with controlled diet, proper medication & a lifestyle change?
2. If Angioplasty is a must, then will it have any side effects in future(on heart or other organs)?

Thanks in Advance!
Posted Sun, 12 Aug 2012 in Hypertension and Heart Disease
Answered by Dr. Raja Sekhar Varma 2 hours later
Thank you for your query.

From the details that you have given, it is evident that your father has had a major heart attack, which was due to a blood clot within the left anterior descending coronary artery. The blood clot has been dissolved with a thrombolytic drug which was given elsewhere, but the underlying plaque of cholesterol deposits and other debris persist in the artery and has produced an 80% blockage of the artery.

This also means that, while there is permanent damage to some parts of the heart muscle, there is a definite area around this that is still alive but which is not functioning properly due to deficient blood supply. By doing angioplasty and improving the blood flow to this segment, significant improvement can be expected.

Medical management alone may not always be sufficient or safe to prevent ischemia, recurrent blood clot formation and further damage to the heart muscle. Usually, blockages less than 70% in severity can be treated safely by medicines alone. A major blockage in a critical location like this usually needs to be addressed by angioplasty or surgery.

Angioplasty is not a substitute for medicines. Drugs for sugar, BP and cholesterol control need to be taken lifelong, along with certain other medicines to prevent another attack and drugs to improve the pumping ability of the heart.

Angioplasty is a relatively safe procedure these days with low complication rates <5%. The kidney function has to be good when the procedure is done, so that the XXXXXXX that is used to visualize the arteries and the blocks is excreted through the kidneys.

The two major issues after such a procedure are the risks of reblockage (either due to blood clots forming within the stent or due to restenosis where the blockage comes back) and bleeding during the procedure. The proper usage of medicines will reduce the risks of bleeding and stent thrombosis, while the usage of drug-eluting stents will reduce the risk of restenosis. The risks do not come down to zero, however. Yet, the benefits of the procedure far outweigh the risks.

If you want to objectively document whether angioplasty will be beneficial or not, you can get a viability testing done. This can be done either by stress myocardial perfusion imaging (using radionuclides) or by dobutamine stress echo. With the help of these tests, the actual amount of scar tissue (permanently damaged tissue without hope of improvement) and viable ischemic tissue (which will improve after angioplasty or surgery) can be determined. If there is a significant proportion of viable tissue, it is better to do angioplasty. If there is only scar tissue without much viability, there is no point in doing angioplasty.

In view of the fact that he was given thrombolysis and there is an 80% stenosis (not a completely blocked artery), it is likely that he has a significant amount of viable tissue.

I hope this answers your query. Feel free to ask me for any further clarifications.
With regards,
Dr Raja Sekhar Varma, MD(Medicine), DM (Cardiology) (JIPMER)
Consultant Interventional Cardiologist, XXXXXXX Hospitals-DSI, Banashankari, Bangalore
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