Do coronary artery stents work?

Stenting the coronary arteries for angina is one of the most commonly performed procedures performed today.
There is no debate that in patients with unstable angina (chest pain at rest or about to have a heart attack,) stenting is lifesaving. There is however some discussion on whether cardiologists are stenting more patients than they should. For example there is no evidence that it increases mortality or recurrent heart attacks, but until recently we have always believed that it reduced pain.

In the last few days a recent trial called OBITA has suggested that stenting for single coronary artery disease may be no better than a dummy procedure. In this study, 200 patients in the United Kingdom with only one narrowed coronary artery, were either stented, or had an angiogram but no stent, and then were followed up. At 6 weeks there was no difference in the patient's assessment of angina. (There was however improved exercise time, evidence of ischaemia (poor function) on stress echocardiogram, and the patients who had the dummy procedure were on more medications.

Nevertheless this has ruffled many feathers in the cardiac community.
While waiting for more evidence, what can we say?
1. Angioplasty and stenting is effective and lifesaving in patients with unstable angina.
2. The study was only for single coronary artery disease, and cannot be applied to patients requiring multiple stents.
3. It does mean that we shouldn't be so eager to step in and stent everything, if the patient is not getting a lot of angina (in the study this was the case), just because we show a narrowing in one coronary artery does not mean it should be stented.
4. Stenting is still the treatment of choice if the patient is getting a lot of angina, despite optimal medical treatment.

I believe this study simply confirms that we are stenting to many patients, but there is a real role for using this procedure as part of good cardiology management.

What to do when you have a heart attack

What to do when you have a heart attack

What happens:
One in three of us will die of heart disease, and although becoming slightly less common, a heart attack remains the major cause of death.With a heart attack a fat laden plaque in a coronary artery ruptures, causing a clot which blocks the artery. This can lead to a number of consequences:
1. Chest pain – a tight heavy feeling in the chest, throat, left or right arm,

2. Breathlessness, sweating, faintness and a feeling of being generally unwell frequently happen.
3. The heart can sometimes beat irregularly, causing palpitations, sometimes it can stop or beat in an uncoordinated fashion (ventricular fibrillation), leading to sudden death.

Speed is of the essence - both to reduce the amount of heart damage long term, and also reduce the risk of sudden death.   In the cardiology literature - "minutes mean muscle', ie the longer the delay, the more heart damage occurs. 
If we can dissolve the clot in the artery rapidly (less than 30 minutes) no damage is done at all. However there is benefit up to 6 hours, some believed 12 hours. However at any stage a cardiac arrest can occur, which is why the patient needs to be in a cardiac unit or close to a defibrillator as fast as possible.

While doctors can do –
1. Dissolve the clot with drugs given intravenously (thrombolysis). 

2. Remove the clot and open up the arteries in the cardiac catheter lab – angioplasty and stenting.
3. If the heart goes into fibrillation, this can easily be reversed with a defibrillator. These are routinely present in ambulances, places where people congregate (sports stadium, airports, shopping malls) and of course cardiac units.

What you can do –
1. Get to a cardiac unit (or ambulance) as soon as possible.

Call the ambulance using the emergency number (111, 999, 911) and say you have chest pain.
2. Sit down quietly and relax, if you feel faint lie down flat.
3. Chew one aspirin tablet (300 mg) slosh it round the mouth and then swallow it. This prevents the clot in the artery getting bigger.
4. If you have one, use your Nitrolingual spray one or two puffs every five minutes.
5. If you have some available, take some chewable magnesium or liquid magnesium (500 – 1000 mg), and 1000 mg of omega-3 fish oil. Both of these can  reduce the risk of cardiac arrest.

8 year survival curves, shortest delay (top) to slowest (bottom)

A recent study from the Netherlands has shown that in 3000 patients with a heart attack, the 30 day mortality was 2.6% in those with the shortest delay in reaching hospital catheter lab (mean 72 minutes), compared to 7.4% in those with the longer delay (160 minutes).   Five year mortality was also reduced from 22.6% in those with the longer delay to 12.8% in the shortest delay. 

So - getting to hospital as fast as possible saves lives in both the short and longer term.  DO NOT DELAY, don't worry about a false alarm or being a nuisance, any chest pain lasting more than 10 minutes, call an ambulance!