Angioplasty or percutaneous coronary intervention (PCI) is a common nonsurgical procedure used to restore blood flow to blocked arteries, particularly the coronary arteries that feed the heart. (PCI also has been known as percutaneous transluminal coronary angioplasty or PTCA). Coronary artery disease (CAD) is the result of atherosclerosis, a condition that causes a buildup of material called plaque on the inner walls of arteries. PCI reduces symptoms (such as chest pain known as angina or shortness of breath), reduces the damage done to the heart by a heart attack, and reduces the risk of death in some patients. Today, the use of PCI is far more common than use of coronary artery bypass surgery, which was once the only means available of opening dangerously blocked arteries. PCI is far less invasive than open heart surgery, greatly reducing recovery time and risk. But for individuals with severe heart disease, multiple blocked coronary arteries, or additional medical problems (e.g., diabetes or heart failure), bypass surgery still may be the best option. Today, this surgery is highly effective and safer than it was a generation ago.
Doctors performing PCI will feed a small balloon or other device on a thin tube (called a catheter) through blood vessels to the point of blockage and then inflate the balloon to open the artery. If necessary, a stent may be used to keep the artery open. A stent is a wire mesh tube or "scaffold" that is left in the artery to keep the arteries from closing up again. Serious complications are uncommon during PCI and stenting, but they can happen no matter how careful your doctor is or how well he or she does the procedure. PCI should be performed by experienced physicians at institutions where the volume of these types of procedures is high. Ideally, physicians performing PCI should perform at least 75 of these procedures per year.
RISK FACTOR MODIFICATION
While genetic factors play a part in who gets atherosclerosis, the World Health Organization estimates that 80% to 90% of people dying from coronary artery disease (CAD) have one or more major risk factors that are influenced by lifestyle. That gives you a lot of power to reduce your personal risk of cardiovascular events by targeting these major risk factors. Once you have developed CAD to the point where you require PCI, it is extremely important that you manage these risk factors to minimize your risk of future need for such procedures and to reduce your risk of heart attack, stroke, and cardiac death.
After PCI, take the opportunity to re-evaluate your lifestyle, including aggressive risk factor modification that can greatly reduce the risk of additional cardiovascular events. Once ischemic disease is evident in the heart, it can often be found in other parts of the body, too, increasing the risk of other problems such as stroke. Fortunately, making a few changes in your life will benefit your entire body and reduce the likelihood of a large number of health problems. Moreover, since CAD tends to run in families — as do major risk factors like smoking and diet — patients who have undergone PCI and their families should learn how to manage major risk factors such as cholesterol, blood pressure, and diabetes. Physicians and their staff can provide valuable information on diet, weight control, physical activity, tobacco cessation, and other appropriate lifestyle modifications. Diabetes greatly increases the risk of future coronary events, which means lifestyle changes are especially important if diabetes is present or there is a strong family history of diabetes.
It is important to remember that the recommendations presented here may not be appropriate for all patients. It is always prudent to discuss your particular situation with your personal physician.
1. Smoking greatly increases the progression of atherosclerosis and the risk of fatal and nonfatal heart attacks and strokes in both men and women. The good news: 1 year after you quit smoking, your risk of a heart attack drops sharply 1 year after quitting and continues to decline over time. Talk to your doctor about ways to help you stop smoking. Options include nicotine replacement using gum, lozenges, inhalers, nasal spray, or nicotine patches. Non-nicotine prescription drugs are also available and they can reduce the severity of nicotine cravings and withdrawal symptoms. The likelihood that you will successfully quit smoking is increased further by participating in stop smoking programs that are offered at many local hospitals and health centers. Besides stopping smoking, individuals who have coronary artery disease should avoid secondhand smoke, too.
2. A number of important lifestyle modifications are recommended for anyone with a blood pressure of 120/80 mmHg or greater. These recommendations include: weight control; increased physical activity; alcohol moderation; sodium reduction (no more than 2.4 gm/day); and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. Blood pressure should be controlled so that readings at rest consistently fall below 140/90 mmHg. If you have diabetes or kidney disease, your resting blood pressure should be below 130/80 mmHg. Most people will require two or more drugs to reach their blood pressure goal.
3. Body mass index (BMI) is a measure of a person’s weight in relationship to their height. There are many tools available online to calculate BMI, including our own tool here on CardioSmart.org. BMI should be assessed regularly. Weight maintenance or weight reduction requires an appropriate balance of increased physical activity, a reduction in calories consumed every day, and, if necessary, formal weight loss programs. If you have undergone PCI, your goal should be a BMI between 18.5 and 24.9 kg/m2.
4. Waist circumference is another important measurement, and can point to the presence of metabolic syndrome (a group of several associated risk factors that greatly increases the risk of future heart problems. A waist circumference of 35 inches (89 cm) in women or 40 inches (102 cm) in men indicates the need for lifestyle changes that will help you lose weight and the need for strategies to reduce your risk of metabolic syndrome. Like BMI, waist circumference should be assessed regularly.
5. When should you return to physical activity following PCI? Daily walking is usually encouraged immediately following healing of the catheter entry site. Exercise can begin within 1-2 weeks after coronary revascularization. If PCI was performed following a heart attack, you usually can return to driving within 1 week of discharge unless prohibited by state law. Patients with a more complicated coronary event should delay driving for 2-3 weeks. Physical activity is very important because it not only improves numerous cardiovascular risk factors but also reduces symptoms in people with cardiovascular disease. Thirty to 60 minutes of moderate intensity daily aerobic activity can be spread out in shorter segments throughout the day and includes activities such as walking, jogging, cycling, etc.; this should be supplemented by an increase in daily activities (such as walking breaks at work, gardening, or household work). In addition to aerobic training, mild-to-moderate resistance training (using weights, for example, or other resistance training equipment) 2 days a week is recommended. Such strength training may start 2 to 4 weeks after aerobic training has begun. If PCI was performed following a heart attack, cardiac rehabilitation programs may be recommended, especially for individuals with multiple modifiable risk factors and moderate- to high-risk patients in whom supervised exercise training may be helpful.
6. At a minimum, low-density lipoprotein cholesterol (LDL) should be substantially less than 100 mg/dl; a reasonable goal is less than 70 mg/dl. There is a wealth of evidence that cholesterol-lowering therapy reduces the progression of atherosclerosis and the risk of future cardiovascular events. Dietary recommendations include:
- Reduce your intake of saturated fats (found mostly in animal products) to less than 7% of total calories, greatly reduce intake of trans fats (also in animal products and most snack foods), and limit cholesterol intake to less than 200 mg/day. (Note: 3.5 ounces of beef has 70 mg of cholesterol; 3.5 ounces of chicken has 60 mg of cholesterol; and one boiled egg has 225 mg of cholesterol.)
- Increased consumption of omega-3 fatty acids in the form of fish or in capsules (1 gm/day) is recommended. (Higher doses may be recommended if you have high triglycerides.)
- As for fiber, your diet should contain 2 gm/day of plant stanols/sterols (found in many fruits, vegetables, nuts, seeds, cereals, legumes, and other plant sources) and at least 10 gm/day of soluble or viscous fiber (concentrated in oats, barley, soybeans, dried beans and peas, and citrus fruit).
7. While LDL is probably the best known of the lipids that occur naturally in the body, there are other measurements obtained in a standard lipid profile: total cholesterol, high-density lipoprotein cholesterol (HDL), and triglyceride levels. There are even different sizes and types of cholesterol particles that affect cardiovascular health, such as very low-density lipoproteins (VLDL) and intermediate-density lipoproteins (IDL). While LDL is an important risk factor, in some patients measuring non-HDL cholesterol (non-HDL) may be better to use as a treatment goal. Your non-HDL cholesterol level is simply your total cholesterol minus HDL, or put another way, it is the sum of your LDL, VLDL, and IDL. If your triglyceride levels are between 200 and 499 mg/dl, for example, your non-HDL cholesterol levels should be less than 130 mg/dl. Further reduction of non-HDL to less than 100 mg/dl may also be reasonable.
8. Hemoglobin A1c (commonly written as HbA1c) is a blood test that reflects the average blood sugar (more properly know as blood glucose) level over a 3-month period. In individuals with diabetes who have had PCI, lifestyle changes (e.g., increased physical activity and management of weight, cholesterol, and blood pressure) are strongly recommended; medications may still be necessary to achieve a normal or near-normal HbA1c (less than 7%).
DRUG THERAPIES
1. Unless you have specific contraindications to aspirin, anyone who has undergone PCI and stenting should take aspirin indefinitely. Aspirin reduces the risk of a blood clot during the period after stenting when your heart vessels are healing. Also, for patients who have experienced a heart attack, daily aspirin reduces the risk of a second heart attack by about one-third. Aspirin and medications known as nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly consumed drugs in the world. However, one aspirin alternative known as ibuprofen may limit the protective effects of aspirin, so ibuprofen should not be taken on a regular basis if you are on long-term aspirin therapy. If you need both daily aspirin to reduce your risk of a heart attack as well as the regular use of aspirin alternatives for pain or other medical conditions, talk to your doctor about which over-the-counter drugs are best for you. Also, if you can’t take aspirin, there are other prescription drugs your doctor may consider to reduce your risk of blood clots after PCI and stenting.
The dose of aspirin recommended after PCI and stenting is a little higher than what is recommended for heart attack prevention alone. Remember, aspirin is helping prevent blood clots during the time that your coronary arteries are healing after PCI and stenting. If you do not have an allergy to aspirin or an increased risk of bleeding, the guidelines recommend higher dose aspirin 162 mg to 325 mg daily for at least 1 month after implantation of a regular (non-coated) stent. If a drug coated stent was implanted, the duration of higher dose aspirin therapy is extended by several months. Once the short-term risk of stent-related blood clots has passed, long-term low-dose aspirin should be continued indefinitely at a dose of 75 mg to 162 mg daily.
2. To further reduce the risk of blood clots after stenting, other drugs may be recommended in addition to aspirin (or as a substitute if you have contraindications to daily aspirin). If you received one of the drug- coated stents, it’s recommended that you take clopidogrel (Plavix®) 75 mg daily for at least 12 months, again assuming that you are not at high risk of bleeding. For post-PCI patients receiving a non-coated stent, clopidogrel should be taken for a minimum of 1 month and ideally for up to 12 months (unless you are at increased risk of bleeding; then you should take clopidogrel for a minimum of 2 weeks). Even if you didn’t receive a stent but underwent PCI following a heart attack, your doctor may recommend you take clopidogrel for at least 14 days; long-term clopidogrel therapy (75 mg per day) may be reasonable for 1 year or longer in some patients. Another drug, warfarin (Coumadin®), a powerful blood thinner, may be recommended in addition to aspirin and clopidogrel in high-risk patients who had PCI following a heart attack. (This includes individuals with atrial fibrillation or other disorders associated with increased risk of blood clots.) Your physician will need to carefully monitor this combination of drugs to reduce the risk of bleeding.
3. Statins are a group of particularly powerful cholesterol-lowering medications commonly used to treat elevated LDL levels. Evidence suggests that statin therapy may be beneficial regardless of baseline LDL cholesterol levels. For reducing non-HDL cholesterol, niacin (a B vitamin) or fibrate therapy are both options for long-term use. They have the added benefit, too, of increasing HDL levels (the good cholesterol). Therapy to increase HDL is sometimes considered when HDL levels are less than 40 mg/dl.
4. Angiotensin-converting enzyme (ACE) inhibitors (a specific class of medications) are highly recommended for patients who have high blood pressure, diabetes, or chronic kidney disease (unless contraindicated because of other health factors). People at high risk, such as those who had a previous heart attack or show a reduction in the pumping function of their heart (reduced ejection fraction) should be considered for indefinite ACE-inhibitor therapy.
5. The guidelines recommend that another class of medications called angiotensin receptor blockers (ARB) be considered for individuals with high blood pressure or heart failure, or who have had a heart attack and have a reduced ejection fraction. Often these drugs are used for individuals who are intolerant of ACE inhibitors or in combination with ACE inhibitors for people who have heart failure.
6. An aldosterone blocker is recommended for individuals without significant kidney problems who are already on an ACE inhibitor but need additional treatment due to a low ejection fraction, heart failure, or diabetes.
7. After a heart attack, the guidelines suggest starting and continuing beta-blocker therapy for at least 2 to 3 years (sometimes indefinitely) except in people with extremely good prognosis or who have contraindications to this particular drug. Beta-blockers are a class of medications that typically lower heart rate and blood pressure, reducing the heart’s workload. Even some people who are considered low risk for recurrent events are prescribed beta-blockers to minimize the likelihood of recurrent ischemic symptoms and to help control the surges of heart rate and blood pressure that occur with exertion.
OTHER
Every year in the United States, influenza ("the flu") causes more than 36,000 deaths and 225,000 hospitalizations. Individuals with chronic conditions, such as cardiovascular disease and diabetes, are particularly vulnerable to complications of the flu. Vaccination during the flu season has a critical but under- appreciated role in the prevention of death or hospitalization. That’s why the guidelines now suggest that any child or adult with cardiovascular disease should have an annual flu shot.
Guideline-Based Standards of Care: What You Should Know
The American College of Cardiology (ACC) and the American Heart Association (AHA) work together on an ongoing basis to publish Guidelines addressing standards of care for the diagnosis, management and prevention of cardiovascular disease. The ACC/AHA Guidelines represent a consensus of expert medical opinion, with the goal of establishing a standard on which to base cardiovascular care decisions, serving the patient’s best interests.
The guidelines are intended to help health care providers and patients make informed, best-possible decisions regarding care for specific clinical circumstances. The ACC strongly believes that adoption of these standards leads to higher quality cardiovascular care, cost-effectiveness, and most importantly, better outcomes for patients.
Please note that the ACC/AHA Guidelines attempt to define practices that meet the needs of most patients in most circumstances. However, everyone is unique, and the extent to which the guidelines apply specifically to you should be a key point of discussion between you and your cardiologist or health care provider. The ultimate judgment regarding your care must be made by you and your healthcare provider together, in light of circumstances specific to you as a patient.
Although all ACC/AHA Guideline documents are freely available, and can be downloaded from the ACC’s Cardiosource web site, these documents are often extremely long, and written primarily for the healthcare provider. Here at CardioSmart you will find a summary of the key points from the Guidelines, written specifically with the patient in mind. We urge you to review these key points, print them out if you like, and engage your healthcare provider in a discussion of how the guidelines relate to you and your condition.
That is, after all, what being CardioSmart is all about – being empowered to work with your physician in managing your care to assure the best possible outcome!
If you’d like to read the full guidelines from which this summary is derived, please click on either of the links below. Please note that these documents are large, so please have patience while they load.
ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention
AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update