Coronary Artery Disease, Coronary Stenting

Coronary & Heart Muscle Diseases

Coronary and heart muscle diseases involve conditions that affect the heart’s blood vessels (coronary arteries) and the heart muscle (myocardium) itself. These diseases can impair blood flow, weaken the heart, or lead to heart failure if left untreated. Common examples include heart attacks, cardiomyopathy, and congestive heart failure. They are often caused by a combination of unhealthy lifestyle factors, genetic predisposition, or other underlying health conditions such as hypertension, diabetes, lipid disorder, and kidney disease. Early detection of cardiac risk factors and global cardiac risk, and the current extend or burden of the disease are essential (by performing all patient stent test, echocardiogram, calcium cardiac score, CT cardiac scan or combination). Collaboration between the patient and physician is essential in managing existing conditions such as coronary artery disease requiring stenting or coronary artery bypass graft (CABG) surgery, optimizing lipid levels, treating metabolic syndrome (insulin resistance), controlling diabetes and hypertension, smoking cessation, achieving a weight loss goal of approximately 10%, increasing physical activity to recommended levels, managing sleep apnea, and appropriately addressing anxiety and stress. Additional treatment strategies may be tailored to each individual’s specific needs. Successful management also requires building a strong level of trust between the patient and cardiologist, allowing them to work together as a team. This partnership supports adherence to medication titration, encourages positive feedback and reinforcement, promotes open communication, facilitates follow-up testing, and ensures regular outpatient follow-up visits.

Heart Attack (Myocardial Infarction)

A heart attack occurs when blood flow to a part of the heart muscle is blocked, causing acute decrease in oxygen delivery to the affected part of the heart muscle the leads to permanent tissue damage or (infraction).

Possible Causes:

• Coronary Artery Atherosclerosis disease – lipid plaque results from the buildup of either lipid-rich plaque or calcium fibrotic plaque, or more commonly, a combination of both (Calcium inflammatory plaque and lipid plaque) in the coronary arteries, which causes restriction of blood flow.
• Blood Clots – can suddenly block a coronary artery. This usually happen from a rapture of a coronary clot, or less commonly from other systemic illness.
• Demand Ischemia – very fast heart rate due to arrhythmias or a serious life threatening condition (major surgery related stress, severe infections, major trauma or blood loss) in a patient with underlying moderate degree of coronary artery narrowing can cause a heart attack.
• Dysfunction of Small Coronary Artery – Endothelial dysfunction, coronary microvascular disease, inflammation of the coronary arteries (vasculitis), and other (Takotsubo) can lead to damage of myocardium.
• Spontaneous Dissection of Coronary Artery (SCAD); – but rare condition where there is a tear in one of the three layers of a coronary artery wall. This is usually occurs in other wise healthy young women during or after pregnancy, or possibly genetics, hormonal factor or inflammatory changes.
• Traditional Risk Factors– can accelerate damage to coronary arteries. Each risk factor has its own risk and when multiple risk factors are poorly controlled then the total risk will a multitude of those risk factors. For example: A current smoker has 3.0 times higher risk than non-smoker, uncontrol hypertension has 4.1 times higher risk, diabetes has 2.6 times higher risk and so forth. Combining two risk factors such as: smoking with dyslipidemia, or hypertension, or diabetes can result in upto 8 fold increase in the risk of multi-vessel coronary artery disease.

Signs and Symptoms:

• Chest pain or pressure – often described as tightness or squeezing.
• Shortness of breath – due to reduced oxygen supply to the body.
• Nausea or vomiting – caused by autonomic nervous system response.
• Sweating and dizziness – common during acute episodes.
• Silent coronary artery disease (asymptomatic) – larger observational studies on general population who underwent coronary CT scan angiography showed that 36% of patients has a non-obstructive mild to moderate disease, and 10% of them have obstructive disease (>50%) narrowing. Additionally, observational studies on patient who underwent nuclear stress testing, demonstrated that the finding of abnormal high-level of ischemia (>7.5% of heart muscle involved) to be present in about 6% of asymptomatic patients. It’s well known now that a silent CAD condition (Silent CAD especially the obstructive type) is linked to a 8-12 times higher risk of future heart attack.

Possible Care Treatments:

• Emergency angioplasty – opens blocked arteries to restore blood flow.
• Medications – blood thinners, beta-blockers, and clot-dissolving drugs.
• Lifestyle modifications – quitting smoking, healthy diet, and exercise.
• Cardiac rehabilitation – structured program for recovery and heart strengthening.

Benefits of Care:

Reduces mortality, prevents further heart damage, improves heart function, and lowers risk of recurrent heart attacks.

Coronary Artery Stenting

Coronary artery stenting is a procedure in which a small mesh tube (stent) is placed in a narrowed or blocked coronary artery to keep it open. It is commonly performed during angioplasty to restore blood flow to the heart. Stenting helps prevent chest pain (angina) and reduces the risk of heart attack. The procedure is minimally invasive and usually allows patients to return to normal activity relatively quickly.

Possible Indications for Stenting:

• Acute Coronary Syndrome – acute myocardial infarction.
• Unstable Angina – increase in frequency of episode in chest pain, or severity despite a good anti-angina treatment.
• Chronic Ischemic Heart Disease – that cause decline of the function of the heart muscle despite a good medical management.
• Chronic Refractory Anginal Chest Pain – or a variant of it (dyspnea on exertion); sentence continues to affect quality of life along with abnormal finding of this recent stress test and despite a good medical treatment. Stenting is needed to help with sentence and quality of life.
• High Risk Finding in a non-invasive cardiac stress test or abnormal special study called (FFR) Fractional Flow Result.
• Previous history of sub-optimal angioplasty and continued sentence.
• In-stent restenosis is more than 40% residual narrowing.
• Certain selective cases: patient has known significant disease and medically treated but requires a high risk surgery, a heart valve procedure, other major heart surgery, or has a high risk profession (commercial driver, machine operator, a pilot, military, etc), certain conditions of blockage of previous coronary bypass graft, or selective cases of chronic total occlusion of coronary artery.

Other Treatments

In addition to Coronary Stent Intervention:

• Medication – antiplatelet therapy (Clopidogrel-Plavix, Ticagrelor-Brilinta, or Prasugrel -Effient); this is an essential drug that need to be given an uninterrupted to prevent stent thrombosis for approximately 1 full year. It’s important to know that if you are taking this medication and other doctors ask you to stop the medication for a plant elective surgery or dental procedure that you consult us before discontinuation to avoid a life threatening complications from stopping the medicine. Additionally, low dose aspirin 81mg, beta blockers, and cholesterol lowering medication.
• Additional medication can be sometimes added, Nitrates medicine to help with angina relief, calcium channel blockers (Amlodipine), Ranolazine, Nicorandil, Ivabradine, and Trimetazidine to optimize heart metabolism especially in diabetic patient.
• Lifestyle changes – diet, exercise, and smoking cessation.

Lithotripsy of Arteries (Intravascular Lithotripsy)

Lithotripsy of arteries is a minimally invasive procedure used to treat heavily calcified coronary arteries. It uses sonic pressure waves to break calcium deposits, making it easier to place stents. This procedure is particularly helpful when traditional stenting is difficult due to rigid arterial walls. It improves blood flow and reduces procedural complications during angioplasty.

Possible Causes for Artery Calcification:

• Aging – natural calcification occurs over time.
• Diabetes – accelerates arterial calcification and stiffening.
• Chronic kidney disease – disrupts calcium-phosphate metabolism in vessels.
• Tobacco use – smoking introduces that directly endure the artery and cause inflammation that lead to calcification.
• Metabolic conditions – insulin resistance, central obesity, lack of physical activity, consuming unhealthy diet (high in simple sugar, processed meat, food preservatives, trans-fat, saturated fat and low in fiber) will lead to oxidative stress and inflammation.