Heart disease is challenging and frightful. Sometimes decisions are made very quickly regarding managing the disease process. Heart disease is a chronic condition that rears its ugly head over and over for many. As a heart patient your best off having a good knowledge of the disease process and the choices of interventions. Methods of intervention include:
- Angioplasty (balloon opening of artery)
- Cutting balloons and roto ruters
- Drug eluting (coated) stent
- Open heart surgery – Bypass Surgery
- Treat medically with medicine and lifestyle
- Enhanced Eternal Counter pulsation therapy
- Left Ventricular Assistive Devices
- Heart Transplant
Many of these decisions are based on the amount of heart tissue that is involved. If there is a large region with insufficient blood flow caused by numerous blocked vessels you most likely will be recommended to have bypass surgery. The general rule is if three vessels are involved you will most likely require surgery. You do have choices though, as the main blockage can be intervened on through stents and the other vessels can be addressed at a later time. We call this staged stents. The cardiologist do not recommend placing stents to both the right and the left side of the heart during the same intervention. They will treat the culprit, and then come back later for the others. The decision tree also takes into account what other issues (co morbidities) a patient has. If a patient has end stage renal disease or their kidneys were severely affected by the heart problem then the physician my want to avoid treatments that place a heavy burden on the kidneys such as angioplasty or stents. They may opt to treat medically until the kidneys have recovered if they can.
A single vessel blocked will more likely be treated with a stent. However the location of blockage can be very challenging. If the blockage is where the artery separates to another branch – called an anastamosis these are very difficult to deal with because a stent would block the flow to the other artery. Sometimes they require surgery, new technology in stents is coming and these may be able to be stented in the future. Some vessels are too torturous – meaning twisty and turny to allow a stent to be placed. Again surgery, treat medically or EECP therapy would be considered.
Small vessels are less likely to be treated with stents and more likely to be treated with medications. Medication includes nitro, long acting nitro, calcium channel blocker, ace inhibitors, beta blockers and occasionally EECP.
Intervention is determined by how viable the heart muscle is. If the heart muscle was severely damaged due to a heart attack and now scarred over – or remodeled, further intervention to that region is not likely to be of any help.
EECP – it is enhanced external counterpulsation therapy. The therapy consists of cuffs wrapped around legs, calves and buttocks. When the heart finishes pushing the blood flow out, the cuffs sequentially inflate to push the blood back up the heart. By doing this the heart is somewhat engorged with blood and forms collateral vessels. The treatment consists of one hour treatments 5 days a week for 7-9 weeks. Most patients find their frequency and intensity of angina is greatly diminished. Many patients hold the benefits for 2-5 years, but others will require more frequent return treatments to hold the gains. It is usually covered by insurance such as Medicare if the angina is considered functionally limited or disabling. For some people with very serious heart damage this improves the pumping ability of the remainder of the heart muscle, as it becomes stronger due to increased blood flow from collateral arteries. The EECP alone will not maintain the benefits, you must still keep physically active through exercise to maintain the benefits. The treatment is non invasive.
LVAD is a left ventricular assistive device. These are used when the heart cannot meet the demands any longer to adequately circulate the blood. For many this is now considered a destination therapy. This means they will not be a candidate for a heart transplant but will forever rely on the mechanical pump to circulate their blood. These are becoming more frequently used, and the mortality rates are decreasing with these pumps. If your health care provider is contemplating this route for you, I would strongly suggest you contact support groups of patients who already have LVADS here is a Facebook link to such a support group.
Heart transplants are necessary when the damage is such that the heart cannot meet the needs. Often the patient is repeatedly hospitalized in congestive heart failure. They are disabled due to the heart condition.
The take home is know the procedures, research the pro’s and con’s of each. Don’t walk in to the physician’s office and simply take the first suggestion. Question the efficacy, ask the probability of success and what are the limitations, what can you expect in the future. Be active in your healthcare. Most inpatient nurses will tell you they witness too many incidents where the health care provider tells the patient and family if you don’t do this you will die. Thus the patient feels compelled to have the intervention performed. You have choices.
Choices involve the above discussion, but also include risk factor modification every single day. Choose to exercise, choose to eat healthy, choose how to respond to stress, choose to take your medications, choose to not smoke, choose to monitor blood sugar.
Left Ventricular Assistive Device
Enhanced External Counterpulsation Therapy