Medihub - Medical Information - Cardiology - Management of Stable Coronary Artery Disease

What is Coronary Artery Disease?

1. Stable Coronary Artery Disease

Stable coronary artery disease (“blockage” of blood vessel supplying the heart) refers to a condition when a patient experiences chest discomfort only on moderate to strenuous physical exertion, which is relieved completely by resting. By being “stable”, the symptom has to be unchanged over a period of time.

2. Unstable Coronary Artery Disease

In contrast, unstable coronary artery disease refers to conditions where patient develops chest discomfort at rest or during sleep, which is persistent or progressive. Unstable coronary artery disease almost always require hospitalization and usually will benefit from aggressive invasive treatment such as percutaneous coronary intervention (“ballooning” and “stenting”) or coronary artery bypass operation.

Treatment Options

Nowadays, there are three major options for the treatment of stable coronary artery disease.

1. The first option is to start the patient on a regime of medications with different mechanism of actions.

The advantages of this option include noninvasive in nature (usually safe), ease of administration, well tolerated, and importantly, cheaper in cost. Many large clinical trials have been done and conclusively established the benefits of medical therapy in reducing coronary events, angina (chest discomfort associated with inadequate oxygen supply to the heart tissue), and improving long term outcomes. With the advancements in cardiovascular pharmotherapy, this treatment option is becoming increasingly attractive. This is especially important for patients who are afraid of invasive therapy that involves needles, inserting tubes into the coronary blood vessel and even an open chest operation.

The disadvantages of medical treatment alone include discipline lifestyle to comply with the regimes, restricted physical activities in some cases, and side effects from polypharmacy.

2. An alternative to medical therapy is percutaneous coronary intervention (coronary angioplasty).

This procedure involves the insertion of a small (1.5-2.5mm) plastic catheter (tube) via either the femoral (groin) artery or radial (forearm) artery. The plastic catheter is then used to engage the specific artery. Through the inner lumen (tunnel) of the catheter, expandable balloons and stents (metal mesh which acts as a scaffolding to hold the artery open) are then delivered to the specific area in the artery that require treatment.

The procedure is minimally invasive and most patients will be able to be discharged home within 24 hours. The main benefit of this procedure is to reduce the frequency of angina and improve the quality of life of a patient. It has not been shown to prolong life expectancy.

Since the first coronary angioplasty performed in 1977, interventional cardiology has come a long way with much better equipments, improved techniques and very low complication rate. The latest stents are coated with medications that reduce scarring into the stent.

Recently, there are some controversies over the routine use of these stents due to some reported cases of late clot formation more than one year after stent implantation. Improvements are being developed and more new stents will be available in the future to combat this problem. For the meantime, the main disadvantages of this strategy is the risk of late clot formation, the requirement to take more than one blood thinning medications (which may increase the risk of bleeding), and the relative high treatment cost.

3. Another treatment option for stable coronary heart disease is coronary artery bypass surgery (CABG).

This treatment involves a major open chest operation that will require much longer recovery period. The main advantages include better long term durability of treatment, may improve life expectancy in some cases, and can fix all blockages in one operation. The downsides, apart from longer recovery, include large scars on chest and lower legs, higher risk than medical or coronary intervention treatment, and expensive. Coronary bypass surgery usually lasts for about 10 years and may need to be repeated at a much higher risk the second time.

Deciding on the appropriate treatment

The key question is which treatment option is the best one. Unfortunately, this question is not a straight forward one. One should only make a decision after understanding all the pros and cons of each treatment options. This decision should incorporate a patient’s disease severity, preferences, lifestyle requirements, cost consideration, availability of expertises, and risk tolerance. The decision on how to treat an individual patient should involve a detail discussion between the doctor, the patient and his/her family.