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THE BEST CARDIOLOGISTS IN YELAHANKA Indications for coronary angiography 1 Angina not responding to medical treatment in a patient without contraindications (e.g. extreme old age—usually older than about 85 these days—or severe co-morbidities) to cardiac surgery or angioplasty. 2 Continuing chest pain whose cause is not clear despite non-invasive investigations. The procedure may well be worthwhile if it reveals normal coronary arteries and prevents a patient being treated unnecessarily with more and more anti-anginal drugs. Non-invasive investigations are more often equivocal in women, and more women than men are found to have normal coronaries at angiography. 3 Preparation of a patient older than 35 or so for some other cardiac surgery (e.g. valve replacement). The surgeon needs to know whether significant coronary disease is present so that coronary grafting can be performed at the time of valve surgery. Otherwise, patients are at risk of ischaemic problems in the post-operative period. 4 Diagnosis of cardiomyopathy (p. 267) by excluding coronary artery disease and infarction as the cause of angina or cardiac failure. These patients may benefit from revascularisation if significant coronary disease is also present (‘ischaemic cardiomyopathy’). 5 Investigation of patients following myocardial infarction. Routine transfer to a centre with angiographic facilities after successful thrombolytic treatment is a grade D recommendation. There is no proof that a patient without continuing ischaemia has an improved prognosis when angiography and revascularisation are carried out routinely after infarction. The Open Artery Trial results suggest there is no benefit compared with optimal medical treatment for patients without ischaemic symptoms in having an occluded vessel opened five days or more after an infarction. However, spontaneous or induced ischaemia (by modified stress testing or perfusion imaging) leads to a grade B recommendation for angiography and intervention. The management of post-infarct patients is definitely easier if the coronary anatomy is known, and many units adopt the policy of early (within a week) angiography of infarct patients without contraindications to revascularisation. 6 Non-ST elevation acute coronary syndromes (p. 156). 7 Acute myocardial infarction in a unit where primary angioplasty can be performed
IHEART SPECIALISTS IN HEBBALA ndications for coronary angiography 1 Angina not responding to medical treatment in a patient without contraindications (e.g. extreme old age—usually older than about 85 these days—or severe co-morbidities) to cardiac surgery or angioplasty. 2 Continuing chest pain whose cause is not clear despite non-invasive investigations. The procedure may well be worthwhile if it reveals normal coronary arteries and prevents a patient being treated unnecessarily with more and more anti-anginal drugs. Non-invasive investigations are more often equivocal in women, and more women than men are found to have normal coronaries at angiography. 3 Preparation of a patient older than 35 or so for some other cardiac surgery (e.g. valve replacement). The surgeon needs to know whether significant coronary disease is present so that coronary grafting can be performed at the time of valve surgery. Otherwise, patients are at risk of ischaemic problems in the post-operative period. 4 Diagnosis of cardiomyopathy (p. 267) by excluding coronary artery disease and infarction as the cause of angina or cardiac failure. These patients may benefit from revascularisation if significant coronary disease is also present (‘ischaemic cardiomyopathy’). 5 Investigation of patients following myocardial infarction. Routine transfer to a centre with angiographic facilities after successful thrombolytic treatment is a grade D recommendation. There is no proof that a patient without continuing ischaemia has an improved prognosis when angiography and revascularisation are carried out routinely after infarction. The Open Artery Trial results suggest there is no benefit compared with optimal medical treatment for patients without ischaemic symptoms in having an occluded vessel opened five days or more after an infarction. However, spontaneous or induced ischaemia (by modified stress testing or perfusion imaging) leads to a grade B recommendation for angiography and intervention. The management of post-infarct patients is definitely easier if the coronary anatomy is known, and many units adopt the policy of early (within a week) angiography of infarct patients without contraindications to revascularisation. 6 Non-ST elevation acute coronary syndromes . 7 Acute myocardial infarction in a unit where primary angioplasty can be performed . Risks of cardiac catheterisation Cardiac catheterisation is an invasive procedure and patients must be aware of
THE BEST HEART SPECIALISTS IN BANGALORE Angioplasty Balloon dilatation of coronary artery stenoses was first performed in the late 1970s by Andreas Grunzig. The technique has undergone many refinements and is now widely used for the treatment of angina not responding to medical treatment. Angioplasty has not been shown to improve the prognosis of patients with stable angina. Coronary artery bypass grafting (CABG) has similarly not been shown to prolong life for most stable angina patients. However, both treatments are very successful in relieving the symptoms of angina. The COURAGE Trial compared optimal medical treatment of angina with angioplasty but excluded patients with symptoms refractory to medical treatment.1 Not surprisingly, this group of stable mild angina patients had a similar outcome with angioplasty and medical treatment. The trial suggests that compared with optimal medical treatment, angioplasty is a safe and slightly more effective treatment for stable angina. Patients can make an informed choice between these two treatments. The majority of patients treated with angioplasty in Australia have acute coronary syndromes and here there is good evidence of prognostic benefit with angioplasty compared with medical treatment. In many centres one-, two- and complicated three-vessel disease are managed this way. It has been shown to be as effective as coronary surgery for these patients but at the price of a higher rate of re-intervention. This is because the greatest limitation of angioplasty is the rate of restenosis in vessels that have been dilated. Restenosis
CARDIOLOGIST IN DODDABOMMASANDRA, BANGALORE Cardiac rehabilitation Although rehabilitation has been a part of the management of patients following a myocardial infarction since the beginning of the last century, ideas have changed radically about the form this should take. In the early 1900s Sir Thomas Lewis insisted his patients remain in bed and be ‘guarded by day and night nursing and helped in every way to avoid voluntary movement or effort’. These severe restrictions were continued for at least six to eight weeks. The thinking was that complete rest would reduce the risk of aneurysm formation and avoid hypoxia that might cause arrhythmias. Even after discharge mild exertion was discouraged for up to a year and return to work was most unusual. In the 1970s periods of bed rest of between one and four weeks were enforced and patients remained in hospital for up to four weeks. It is now clear that this de-conditioning has many adverse physical and psychological effects. Patients with uncomplicated infarcts are now mobilised in hospital within a day or so of admission and are often discharged on the third day if successful primary angioplasty has been performed. Many hospitals provide a supervised rehabilitation program for patients who have had an infarct or episode of unstable angina. The program begins in hospital as soon as possible after admission. It includes a graded exercise regimen and advice about risk factor control. Such programs have many benefits for patients to help them to return quickly to normal life, including work and sexual activity. The supervised exercise regimen helps restore the patient’s confidence. There is clear evidence of the benefits of exercise for patients with ischaemic heart disease.54 Rehabilitation programs have been shown to be cost-effective. Well-conducted programs are tailored to individual patients’ needs and are very popular with many patients.55 There are often long-term exercise groups available for people who have completed the formal classes. Non-cardiac causes of chest pain Pulmonary embolism
BEST CARDIOLOGY HOSPITALS IN BANGALORE Cardiac failure Cardiac failure is an increasingly common condition affecting about 1% of the population but much higher proportions of older people. It is responsible for an increasing number of hospital admissions. The various aetiologies have been discussed above, but the most common cause is now ischaemic heart disease rather than hypertensive heart disease. This reflects the improved modern management of hypertension in the population. The definition of heart failure has always included reference to the inability of the heart to meet the metabolic needs of the body. The earliest concepts of heart failure were of inadequate cardiac pump function and associated salt and water retention. Treatment was aimed at improving cardiac contractility and removing salt and water from the body. In the 1970s the concept of after-load reduction was introduced. This was based partly on the realisation that vasoconstriction was part of the problem. This has led to the modern neuro-hormonal concept of heart failure. It is clear that many of the features of cardiac failure are a result of stimulation of the renin-angiotensin-aldosterone system and sympathetic stimulation. These responses of the body to the fall in cardiac output temporarily increase cardiac performance and blood pressure by increasing vascular volumes, cardiac contractility and systemic resistance. In the medium and longer term these responses are maladaptive. They increase cardiac work and left ventricular volumes and lead to myocardial fibrosis with further loss of myocytes. Most recently it has become clear that heart failure is also an inflammatory condition, with evidence of cytokine activation. Work is underway to establish a role for treatment of this part of the condition. Current drug treatment has been successful in blocking many of the maladaptive aspects of neuro-hormonal stimulation. Many of these treatments have become established after benefits have been ascertained in large randomised controlled trials. These trials have also led to the abandoning of certain drugs (often those that increase cardiac performance) that were shown to have a detrimental effect on survival (e.g. Milrinone). The principles of treatment of heart failure are as follows: 1 Remove the exacerbating factors. 2 Relieve fluid retention. 3 Improve left ventricular function and reduce cardiac work; improve prognosis. 4 Protect against the adverse effects of drug treatment. 5 Assess for further management (e.g. revascularisation, transplant). 6 Manage complications (e.g. arrhythmias). 7 Protect high-risk patients from sudden death.
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