18 May 2010
By Risha Chitlangia
New Delhi, India
Kanta Devi, 67 years old, was rushed to hospital four years ago after she had a heart attack. Doctors told Kanta’s family she needed an angioplasty to open up her blocked arteries. “There was so much pressure on us to say yes to an angioplasty that we couldn’t think logically.” But Kiran, Kanta’s daughter, was lucky because Kiran’s cousin, a cardiologist, told the doctors not to do an angioplasty. “He told them to give my mother thrombolytic drugs. She responded well and was home after five days,” recalled Kiran.
But a number of people know very little about angioplasty and often give in to pressure exerted by cardiologists. Cardiologists say not all heart attack patients need to undergo an angioplasty. If the ECG report indicates ST elevation myocardial infarction (one or more arteries are 100% blocked), then an angioplasty must be done within the first six hours. In the case of non–ST elevation myocardial infarction (one or more arteries are less than 90% blocked), the need for an angioplasty can be evaluated after 24 hours.
“In ST elevation, the blocked artery is supplying no blood to the heart, which makes it necessary to clear the artery,”said Dr V K Bahl, head of the cardiology department, AIIMS.
Doctors say a primary angioplasty is of little use if done after 12 hours in ST elevation MI patients. “The part of the heart supplied blood by the blocked artery will be dead by then. We will not be able to revive it by opening the artery, so there is no point,” said Dr Neeraj Bhalla, senior interventional cardiologist, Max Healthcare.
But since not many people are aware of this basic difference, families are quick to give their consent to an angioplasty. For non–ST elevation heart attack patients, doctors say there are tests available to evaluate the need for an angioplasty.
Doctors say the location of the block, the severity of the block, and the type of diseased artery are some of the crucial factors that have to be kept in mind.
“If the block is towards the end of the artery, then we don’t need to do an angioplasty because the area supplied by it is very small. Cardiologists don’t usually touch an artery if the block is less than 70%,” said Dr Upender Kaul, senior interventional cardiologist, Fortis Healthcare.
But it is important to evaluate the patient in totality. In a heart attack patient with underlying medical complications sometimes doing an angioplasty is a must. Dr Praveen Chandra, chairman, division of interventional cardiology, Medanta Medicity, agrees,
“We have to evaluate a patient in totality. If there is 60% blockage towards the start of one of the main arteries, then we might consider opening it with the use of a stent. A patient’s age is also an important criterion.”
Experts say people with stable anginas are also undergoing angioplasties. With various private and public sector companies including angioplasty in their list of medical benefits for employees, experts say this has resulted in its misuse.
“Minor abnormalities in treadmill tests are highlighted and people are advised angioplasties. Since the employee doesn’t have to pay from his pocket, he is quick to give his consent. Nearly two to five per cent of angioplasties are done on such patients,” said a senior executive with astent–manuufacturing company.
A recent large–scale trial — the Courage Trial — in the US showed medical therapy is as good as a bypass or interventional procedure in stable angina patients.
“Stable angina patients should first be given medical therapy. If pain persists, then they should be considered for an angioplasty. Doing an angioplasty in stable angina patients doesn’t rule out the risk of heart attack in the future,” said Dr Bahl.
But the number of angioplasty procedures in the country is increasing every year. The stent market in India registers a growth of 22–25% every year. “There was a 40% increase in the demand for stents when drug eluting stents were introduced in 2003. Demand has also gone up because of new cath labs opening up in small cities,” said another executive with a stent–manufacturing company. This worries interventional cardiologists because inexperienced doctors are performing angioplasties.
“Angioplasty is a very safe procedure but in the last few years cath labs have mushroomed all over the country. There is a need to keep a check on these cath labs. There should be adequate arrangements at a cath lab to deal with an emergency while the procedure is underway,” said Dr Purshotam Lal, chief, Metro Heart Hospital.
Agrees Dr M Behera, member of the National Interventional Council, “There is a need to monitor these cath labs. The decision to go in for an angioplasty should not be made by a cardiologist alone. A team of doctors should examine a patient and then decide. Every effort should be made to ensure that an angioplasty is done only on a patient who really needs it. We have to stop it from becoming a business. There is a need for a regulatory body.”
Doctors say in young patients of heart attack angiography has better results. ‘It is important to open a blocked artery in young patient as he has a long life ahead and his chances of suffering another attack are high. We have to ensure that all his arteries are open,” said Dr Lal.
Heart Of The Problem
Coronary angioplasty is now a common non–surgical procedure used to open blocked arteries with the help of stents. The stent market has grown dramatically, especially after drug–eluting stents were introduced in India in 2003. Doctors say angioplasty is a safe procedure but also warn of misuse of the procedure. Here’s what you should know before getting a coronary angioplasty done
When To Get It Done Angioplasty is most Beneficial in Heart Attack and Unstable Angina Patients.
Heart Attack Patients
(Acute coronary syndrome) In India, a majority of heart attack patients undergo angioplasty but doctors say not all patients need to. There are two types of heart attack patients:
ST elevation myocardial infarction
Arteries (one or more) are 100% blocked
ECG indicates ST elevation MI
Angioplasty must be done within six–12 hours.
Patient has 99% chances of surviving if angioplasty is done within the first six hours
Almost 70% patients respond well to thrombolysis treatment (in which clot–buster drugs are given)Non–ST elevation myocardial infarction
Arteries (one or more) are not 100% blocked
Angioplasty can be done after 24 hours
Almost 75% patients respond to medication and don’t require angioplasty
A patient should be considered for angioplasty if his Blood Troponin T and I tests are positiveUnstable Angina
Chest pain because of small blockages in the arteries is common these days. Doctors say such patients should be considered for angioplasty only if angina pain persists despite medication
Questions to ask your cardiologist before getting angioplasty done:
In case of a heart attack, check if it is ST or non–ST elevation MI
Number of affected arteries
Which part of the heart is supplied by the diseased artery
Location of the block
Patient’s underlying medical complications
Discuss other options available before going in for angioplastyTypes of Stents Available:
Bare metal stents
Drug eluting stents (most commonly used)
Drug eluting balloonsThe Stent Market In India
Registers a growth of 22–25% per year
Existing interventional cardiology products market is worth $249.3 million (approx)