Complex coronary artery disease and life-saving interventions require a special breed of “cardiology interventionists.”
“One-third of coronary artery disease patients have complex lesions with high mortality risk.”
Coronary artery disease can result from age-related degeneration of coronary arteries and fatty deposits in the arterial walls. Chronic arterial inflammation causes fatty deposits and partial or total blockage of coronary arteries, leading to reduced blood flow to the heart. Insufficient oxygen supply to the heart can result in chest pain, difficulty breathing, and heart failure.
Interventions for coronary artery disease include anticoagulation, angioplasty, stent placement, and bypass surgery. These procedures enable patients to return to their daily lives safely.
But what about interventions for complex coronary artery disease? Can the interventions mentioned above treat the condition? This article provides insight into complex coronary artery disease through the life story of Dr. Suwatchai Pornratanarangsi, a cardiologist specializing in complex coronary intervention.
What is complex coronary artery disease?
Complex coronary artery disease is a coronary artery disease that requires intricate interventional maneuvers. Complex coronary diseases are classified into two groups as follows:
- The complexity of the artery: excessive plaque buildup in the arteries, 100% blocked coronary arteries known as chronic total occlusion, coronary side branch with a long stretch of blockage, bifurcation blockage, a more complex lesion, multi-vessel coronary artery disease, and blockage at a critical locus.
- The complexity of the patient medical conditions: higher risk profile of comorbid conditions such as kidney disease, diabetes, stroke history, old age, and poor health.
In the past, patients with the complex features of coronary artery disease were treated routinely with bypass surgery. However, the procedure is risky and mandates attentiveness and intricate details.
“According to surveys, one-third or 30 percent of coronary artery disease patients have complex features with elevated mortality risk over patients without these features,” said Dr. Suwatchai.
The complex lesions mandate intricate treatments
It is a given that it is more challenging to treat patients with features of complex coronary artery disease as higher expertise and proficiency are mandated. Not every cardiologist is skilled enough to tackle complex coronary artery disease. It requires personal interest, dedication, and long training to reach the skill level required.
According to Dr. Suwatchai, bypass surgery is usually a standard treatment for patients with complex coronary artery disease. However, such a procedure is suitable for patients with few comorbidities and not too advanced an age. Otherwise, postoperative recovery will be prolonged, with potential side effects and more challenging treatment.
Currently, balloon angioplasty or percutaneous coronary intervention (PCI) is capable of supplanting coronary bypass surgery for patients of every gender and age group. These procedures have low risk and are painless and minimally invasive without cutting open the breast bone. However, with the abovementioned incident of complex coronary artery disease, a physician performing complex PCI must be skillful with a deep understanding of the intricacies of the condition.
“I have had patients who are wary of bypass surgery due to advanced age and fear of not surviving it. They gathered all their medical history documents and angiograms to consult me and asked whether I could perform complex PCI for them. I usually evaluate the possibility and strategically plan what to do first and after. Then, I brief the medical staff to prepare equipment. This approach differs from routine cases, where there are fixed sequences for the treatment process.”
During complex PCI, there are variations in the complexity and intricacies among individuals. If the stenosis involves the left main coronary artery, for example, this is highly risky since it perfuses the entire left ventricle. The balloon angioplasty at this locus must be quick and brief to minimize occlusion time. For heavily calcified arteries precluding angioplasty, a rotablator is necessary.
“Sometimes, in addition to skillful cardiologist interventionists and staff, complex PCI calls for more tools and treatment steps than typical coronary artery disease. For example, rotablation - a procedure grinding down calcium deposits with a high-speed drill - is required often in cases of complex coronary artery disease, while the regular cases are not.”
In the case of chronic total occlusion, doctors lack a roadmap of the course of the occluded artery. Therefore, they must marshal their mastery in locating the proximal and distal ends of the arterial occlusion.
“This requires a cardiologist treating complex coronary artery disease to learn more about coronary intervention and utilize more tools. Plus, there is a bifurcation intervention, a procedure that does not require additional equipment but requires individualized techniques of each cardiologist.”
How accessible are expert cardiologists for patients with complex coronary artery disease?
There are meetings of cardiologists interested in treating complex coronary artery disease where consultations, exchanges of ideas, experiences, knowledge, and techniques can occur. These meetings stem from personal interests and challenges faced by each cardiologist.
A group of cardiologists passionate about complex PCI, including Dr. Suwatchai, have a high success rate with complex PCI. Thus, they attract high referrals of patients with complex coronary artery disease.
“A higher volume of complex PCI case mixes helps to hone the skill of a cardiologist like me to become more adept and experienced. For example, for patients with cardiomyopathy, a cardiologist would tap into their experience to plan for equipment to support the heart during a complex PCI procedure. Some cases may require machines that maintain blood circulation or blood pressure, while some may even require ECMO.”
Success of complex PCI: Curative and prevention of recurrence
Recurrent coronary artery blockage after complex PCI is now only 5 percent. Dr. Suwatchai pines for future technological advancement and efficiencies that can push it down to zero, which will be a boon to the quality of lives of patients.
When asked about the risk of recurrent coronary artery disease, Dr. Suwatchai said:
“The five percent of recurrence comes from patients with poor response to balloon angioplasty or those who fail to control for risk factors after the procedure. For example, smoking and negligence in keeping blood pressure, diabetes, or blood lipids under control may lead to the likelihood of recurrent coronary blockage. Another factor lies in suboptimal executed interventions, which depend on how skillful physicians are.”
“Nevertheless, no matter how good doctors are or how strictly patients follow instructions, there is always a lingering chance of recurrent coronary artery disease. Medical science has continually advanced, and I believe one day, it will be possible to eliminate the residual risk. Future technology may result in the production of new materials that increase the efficacy of instruments.”
Life-saving skills that extend life and bestow health to patients
According to Dr. Suwatchai, success metrics for coronary interventions, whether on complex or non-complex coronary artery diseases, are under the two following circumstances:
- Coronary procedures that save lives: Frequently, patients arrive at the hospital on the brink of life and death. When coronary interventions pull them back from the brink, that is a resounding success.
- Coronary interventions that restore health and improve quality of life: Before PCI, these individuals were constantly exhausted and barely able to walk or function. Following PCI, their lives undergo a transformative change. They can walk, return to their daily activities, and rediscover joy and enthusiasm for life.
Especially for patients with complex or severely blocked coronary arteries, many have lost hope in treatment. However, we have successfully treated and saved them, highlighting the importance of the dedication of physicians and medical teams, along with their skills and expertise, in aiding patients. Despite the challenges in treating complex coronary artery disease, medical advancements have been steadily improving and contribute to extending patient life.
How to prevent complex coronary artery disease
We cannot change our genes, choose our parents, or stop age-related decline. We age regardless. These unmodifiable risk factors are beyond our control.
Although these factors are uncontrollable, having a positive family history does not condemn you to developing coronary artery disease. Certain behaviors can trigger and accelerate the progression of these diseases.
Dr. Suwatchai explained that managing known risk factors of coronary artery disease can delay or prevent the condition. These include controlling hypertension, hyperlipidemia, and hyperglycemia -- non-communicable diseases contributing to the development of coronary artery disease. Additionally, avoidable behaviors like smoking are known to harm the heart directly.
Warning signs requiring immediate medical attention
Signs and symptoms of coronary artery disease are classifiable into two broad types as follows:
- Patients with premonitory signs: Chest pain with exertion, relieved by rest. Easy fatiguability
- Patients presented with acute symptoms: Patients have never experienced symptoms of coronary artery disease, but acute symptoms occur due to a rupture of fatty deposits leading to sudden total coronary blockage. It is a cardiac emergency as the out-of-hospital mortality rate is 20 percent, mainly due to a delay in reaching a hospital.
For coronary artery disease prevention, regular health checkups offer early screening results. However, one should not ignore mild symptoms.
“If you experience suspicious symptoms, such as chest pain or abdominal bloating, that you are uncertain if it is due to dyspepsia, gastric acid reflux, or a heart attack, and the symptoms do not improve in half an hour, it is advisable to consult a doctor. Patients should maintain a high level of suspicion as these symptoms could be indicative of coronary artery disease presenting as symptoms of other conditions. If you have multiple risk factors -- despite a young age -- a cardiac health checkup is highly advisable.”
“Because in the blink of an eye, heart disease can unveil its deadly grip, snatching lives with merciless swiftness, leaving no room for intervention. In those critical moments, it is too late; even the masterful hands of skilled cardiologists are tied and rendered powerless.”
