Vibhavadi hospital-style treatment for coronary artery disease

Vibhavadi hospital-style treatment for coronary artery disease

The goal of treating acute coronary syndrome (ACS) is to correct the condition of ischemic heart disease, prevent complications from myocardial infarction, and restore heart function to a level close to normal.

There are many methods for treating this condition, but here we will attempt to explain it in a way that is easy to understand using the "2-3-4" method, which consists of two principles, three goals, and four treatment methods.

The two principles for treating coronary artery disease with myocardial ischemia are:

1. Reduce the workload of the heart to decrease oxygen demand (resting, medication, stress reduction, and avoiding exertion during symptom episodes).
2. Increase blood flow and oxygen supply to the heart (medication, balloon angioplasty, stent placement, and coronary artery bypass surgery).

The three goals of treating ACS are:

1. Correct the condition of ischemic heart disease by preventing or reducing the number of heart muscle cells that die in order to minimize damage to the functioning of the ventricles, or to avoid any damage at all.
2. Prevent complications such as heart failure or arrhythmias in order to reduce the mortality rate and avoid hospitalization.
3. Restore the heart's function to a level as close to normal as possible.

The four treatment methods for ACS are:

1. Coronary artery bypass grafting involves performing surgery to bypass the blocked coronary arteries with healthy veins or arteries taken from other parts of the body.
2. Percutaneous coronary intervention involves widening the blocked coronary arteries by using a balloon catheter, stent placement, or other techniques.
3. Medical therapy involves the use of medications to lower blood lipid levels, prevent platelet aggregation, and reduce blood pressure. Medications such as ACE inhibitors/ARBs and drugs that dilate coronary arteries may also be used.
4. Risk factors such as smoking, high blood pressure, high cholesterol, and diabetes are addressed through lifestyle modifications and medication therapy.

Explanation of treatment for coronary artery disease

The heart muscle works by contracting and relaxing all the time. The heart muscle receives nutrients and oxygen through the red blood vessels of the coronary arteries, which are branches of the main aorta. The pulsation of the coronary artery occurs when the interior walls of the coronary artery are damaged or ruptured, which stimulates the body's mechanism to repair itself. The first thing that happens is the blood clotting mechanism, which causes blood clots to form on the walls of the coronary artery. If the damage is small, the body can repair itself, and the blood vessel's wall cells move to close the wound. This leaves a scar on the interior walls of the coronary artery, called plaque. If there is a lot of plaque, the large coronary artery can become constricted or blocked. When the coronary artery is constricted, the blood and oxygen that nourish the heart decrease, causing chest pain due to the heart muscle lacking blood. The severity of chest pain varies from person to person, but generally, it feels tight and compressed in the middle of the chest and can radiate to the shoulders, back, or left arm. It usually occurs when exerting effort or exercising and goes away when resting. If there is a large blood clot, it can block the entire coronary artery, preventing blood from flowing to the heart muscle, causing severe chest pain suddenly. In cases where the coronary artery is blocked suddenly, the important treatment is to try to open the blocked artery by destroying the blood clot. The blocked blood clot can be dissolved or destroyed in two ways. The first is by performing a procedure called angioplasty to immediately expand the blood vessels using a heart catheterization. The second is by administering medication to dissolve the blood clot. The principle is to try to open the blood vessel as quickly as possible. If this is done within 90 minutes after it is known that the coronary artery is blocked, the heart muscle is less likely to die.

In cases where the coronary artery is narrowed but not completely blocked, we have time to prepare for the best possible treatment. We reduce the need for oxygen by reducing the work of the heart, such as by resting and avoiding getting out of bed, providing medication to reduce the squeezing of the heart, lowering the heart rate, and increasing the amount of blood and oxygen that goes to the heart (oxygen therapy, medication). We assess the risk, examine the heart's function, and perform a heart catheterization to inject contrast dye into the heart's blood vessels to determine the appropriate treatment.

The basic principle of heart catheterization is to insert a needle into the red blood vessel at the ankle or wrist, guide a wire and sheath in, and then insert a catheter about the size of a thin soil probe or dry ink pen (1.5-2 mm) into the blood vessel. The catheter is then pulled up to the area where the coronary artery of the heart is ruptured and the branch comes out. Contrast agent is injected to examine both the left and right coronary arteries to see if there is narrowing. If there is narrowing, the number of positions and the appropriate treatment options are determined, such as balloon angioplasty and stent placement, bypass surgery, or medication treatment. The treatment involves expanding blood vessels by using a balloon and inserting a wire coil is a preferred method of treatment for many patients, but not all are eligible. The method is suitable for cases where the blood vessel has a clear blockage of more than 70%, and the blood vessel is not too twisted or abnormally shaped. It is often used in cases where the heart has 1-2 blocked blood vessels, and if there are 3 blocked vessels, surgery may be a more effective option. If the procedure is done without inserting a stent, there is a 30-40% chance of the blood vessel narrowing again. However, if a bare metal stent is used, the rate of recurrence decreases. If a drug-eluting stent is used, the rate of recurrence is less than 5%. However, no treatment is 100% safe, and potential problems that may arise from this procedure include radiation sensitivity, bleeding at the heart site, kidney failure, arrhythmia, lack of blood flow to certain parts of the heart muscle, blood clots, and tearing of the blood vessel at the stent site, although these are rare. Surgical treatment through bypass surgery is also an option for coronary artery disease.

In cases where there are blockages in multiple blood vessels of the heart, especially in cases where the blockages are long, they are often used in cases where there are three blocked blood vessels, especially diffuse blockages throughout the blood vessels that are not suitable for balloon angioplasty, or in cases of blocked blood vessels at the base of the left main coronary artery or when other treatments have failed, or when there are sudden complications from balloon angioplasty of the heart's blood vessels, such as using the saphenous vein in the leg, the internal mammary artery in the chest, or the radial artery in the arm. Generally, the risk of death from surgery is very low, with a hospital mortality rate of 1-2%. However, the risk of death is higher in elderly patients or those with multiple comorbidities.

Treatment with medication for coronary artery disease and myocardial infarction involves five main groups of drugs, which are drugs that lower blood lipid levels, antithrombotic drugs, beta-blockers or drugs with similar effects, vasodilators, and ACE inhibitors/ARBs. The use of medication is a primary method of treatment for individuals who have mild to severe cases of these diseases and cannot be treated effectively through other methods. Medication may be used alone or in combination with other treatment methods. Certain drugs have been proven to reduce mortality rates in individuals with coronary artery disease and myocardial infarction, such as antithrombotic drugs (aspirin, clopidogrel, and two other new drugs), beta-blockers, lipid-lowering drugs, ACE inhibitors/ARBs, and vasodilators such as nitrates. Nitrates, which come in sublingual, oral, and patch forms, dilate the blood vessels that supply the heart and can effectively reduce chest pain. However, it has not been proven that they can reduce mortality rates.

Behavioral modification: Quit smoking campaign to support patients and their relatives to stop smoking, as smoking increases the risk of heart disease by about three times compared to non-smokers.

Blood pressure control: The goal is to maintain blood pressure below 140/90 mmHg. Recommendations for the general population and adults include regular blood pressure measurement at least every 2 years and lifestyle modifications to prevent high blood pressure. These modifications include reducing cholesterol levels in the blood. The goal is to reduce bad cholesterol levels, and recommendations include simple changes such as avoiding fatty foods, animal organs, poultry skin, red meat, fried and stir-fried foods.

Physical activity: The goal is to exercise for 3-6 days a week, for at least 30 minutes a day, with a heart rate of 60-80% of the target heart rate. Recommendations include lifestyle modifications such as walking more and doing more household chores.

Weight management: The goal is to maintain a body mass index (BMI) between 18.5-23.5 kg/m2, which is considered healthy for Thai people. For those who have excess abdominal fat, there is an increased risk of heart disease and diabetes. Recommendations include controlling blood sugar levels to be close to normal.

Summary

The objective of treating coronary heart disease with myocardial ischemia and muscle ischemia is to correct the condition of ischemic heart disease, prevent complications from heart muscle death, and restore the function of the heart to a state close to normal. There are four main methods of treating coronary heart disease: balloon angioplasty, coronary artery bypass surgery, medications, and addressing risk factors and making lifestyle changes. Addressing risk factors and making lifestyle changes are particularly important because they can reduce or prevent the recurrence of coronary heart disease. As the saying goes, "prevention is better than cure."

Best regards,

Vibhavadi Heart Center