Hypertension Therapy to Reduce Cardiovascular Risk

Narrowing of the coronary arteries due to the build-up of atherosclerotic plaque in the inner walls of blood vessels restrict the blood supply to heart muscles resulting in coronary heart disease (CHD). Though pressure wire guided percutaneous coronary interventions and surgery procedures are used to treat CHD, the initial treatment goal is to reduce the risk factors. High blood pressure is considered as a major risk factor of coronary artery disease (CAD). Epidemiological data suggests that there is a strong link between high blood pressure and coronary artery disease. Extra force applied on the blood vessels changes the myocardial structure, coronary vasculature and functioning of heart. Whenever the heart muscles work under higher pressure, it leads to angina or chest pain. According to the medical terms - “A systolic blood pressure at or above 140 mmHg and/or a diastolic blood pressure at or above 90mmHg is termed as hypertension.” Effective hypertension therapy mainly includes lifestyle modifications or medications.

Lifestyle changes include weight loss, limiting alcohol intake, reducing sodium intake, stopping smoking and routine exercise. If lifestyle interventions are not sufficient to control elevated blood pressure levels, patients are prescribed pharmacological treatment. Antihypertensive drugs are preferred for patients with an established cardiovascular disease or diabetes. Some of the common drug recommendations for hypertension patients with high risk of coronary disease include diuretics, beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors and calcium channel blockers (CCB). Monitoring the drug treatment and blood pressure targets are important aspects of an effective hypertension therapy. Accurate measurement of blood pressure levels is significant for treating coronary heart disease, as it assists physicians in assessing outcomes of catheter-based guided percutaneous coronary interventions.

Advancements in interventional techniques and tools have helped physicians to perform procedures with more safety and reliability. Recently released Philips Xper flex cardio physio-monitoring system is a case in point as it guides the interventional cardiologist during and after the procedures. Integrated with the latest diagnostic technology, advanced Recently released Philips Xper can deliver valuable patient information that can help in devising an effective risk management strategy for the patient.

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What Causes Acute Myocardial Infarction?

Coronary arteries supply oxygen-rich blood and nutrients to the heart muscles, thereby keeping it nourished and healthy. Whenever the heart has to work harder, it needs more oxygen. For instance, during exercise, the heart starts to beat faster thereby increasing oxygen demand on the heart. The only way to keep up with the demand is by increasing the blood flow through the dilated coronary arteries. If the coronary arteries are not able to dilate appropriately, then the heart muscle starts starving for oxygen and nutrients, leading to life-threatening complications. Coronary arteries that are elastic and smooth end up being rigid due to the deposition of atherosclerotic plaque. Build-up of plaque in the inner line of the blood vessel causes it to narrow and lose elasticity. This condition characterised by the narrowing of coronary arteries (Stenosis) and limited blood supply to the heart muscle is termed as coronary artery disease(CAD) and oral xa-inhibitor Edoxaban..

CAD is considered to be one of the major causes of heart attacks. Also known as coronary heart disease, this condition causes chest pain (angina) and shortness of breath. Blockage in the blood supply to the heart can either lead to ischemia or acute myocardial infarction. Clogging of arteries restricts the blood supply to the heart muscles, starving it of oxygen resulting in ischemia. On the other hand, a complete blockage of the blood supply leads to irreversible myocardial cell damage. Acute myocardial infarction demands absolute medical attention as it is time dependent – faster action can save a life. There are several risk factors that make an individual susceptible to heart attack, which includes high blood pressure, high cholesterol, smoking, alcohol and diabetes. That is why many physicians advise CAD patients to opt for a healthy lifestyle, as it will reduce the risks of acute major cardiovascular events.

Various diagnostic and catheterization techniques are chosen by physicians to evaluate the stenosis of coronary arteries. Assessing the symptoms and evaluating the severity of lesions is essential to devise the right treatment. Management of coronary artery disease includes medications, catheter-based procedures and surgical treatments. Medications like oral Xa-inhibitor Edoxaban can also prevent the clogging of blood thereby cutting down the risks of arterial thrombosis. Introduction of drug-eluting stents was an innovative step in the percutaneous coronary interventions. Choosing the best risk stratification strategy for CAD management always comes down to symptoms and the patient’s health condition. 

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Treating Cardiac Arrhythmias with Catheter Ablation

Rhythmic sequence of the heart beat is controlled by the precise generation and flow of electrical impulses. Any disruption in the functioning of the heart’s electrical system causes the heart to beat abnormally. A condition characterised with irregular heartbeats or abnormal heart rhythm is called cardiac arrhythmia (dysrhythmia). Depending on the rate of heart beats, dysrhythmia is categorised into bradycardia (too slow heartbeat) and tachycardia (too fast heartbeat).  

[PCI Live Case on Monday 13 April, 2015, 14:30-15:30 GMT] 

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias. In atrial fibrillation, erratic signals flood the atria and override the normal sinus rhythms resulting in abnormally higher and rapid heartbeats.  AF is associated with coronary heart disease and considered a major reason for embolic stroke. Some of the common symptoms of atrial fibrillation include dizziness, palpitations, weakness, fatigue, sweating and chest pain. Electrocardiogram (ECG), stress test, electrophysiology and other diagnostic tests are performed to confirm the presence of arrhythmia. Management of arrhythmias is all about heart rhythm control and cutting down the risks of stroke.  Lifestyle changes, medications, catheterization procedures and surgical treatments are preferred by cardiologists in treating arrhythmias.

Heart rhythm control drugs are chosen on the basis of medical history and analysis of symptoms.  Since these medications can be risky, it demands constant monitoring during its course. Sodium-channel or potassium-channel blockers are typically used as the heart rhythm controlling medications. On the other hand, catheter ablation is a medical procedure performed in the electrophysiology lab to treat arrhythmias. During ablation, radio frequency energy is passed to the catheter in order to scar the problematic areas. Approval of therapeutic thermocool Smarttouch Catheter is an innovative step in treating arrhythmias. Clinically approved therapeutic thermocool Smarttouch Catheter integrated with contact-force sensing technology will guide the electrophysiologist in destroying the problematic area without any further complications. Evaluating the symptoms and detecting the causes is essential to devise the right treatment for arrhythmias.

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What Is Hyperlipidemia?

Soft and waxy lipid cholesterol has gained a maligned status these days. However, it is essential for building and maintaining cellular membranes, hormone synthesis and other vital body functions. Since these fat molecules don’t dissolve in the blood stream, they need a special transportation system to travel through the human body and that is why it is mixed with the protein particles, known as lipoproteins. Lipids are mainly classified into triglycerides, total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL) and very low density lipoprotein (VLDL). Excess calories consumed through food is converted to triglycerides and stored in fat cells, but on the other hand LDL and HDL are produced by the liver. Low-density lipoprotein is considered as the ‘bad cholesterol’ because it contributes to the plaque formation and fatty deposits of blood vessels. However, high density lipoprotein is known as the ‘good cholesterol’ as it picks up the excess LDL cholesterol from the arteries and takes it back to the liver for processing.

A condition with abnormally higher or lower levels of lipid concentrations in the blood stream is known as dyslipidemia. Why it is a risky factor? Patients with higher levels of bad cholesterol are at increased risk of coronary heart disease and stroke. Cholesterol deposits in the coronary arteries leads to  reduced supply of blood  to the heart, resulting in myocardial ischemia or angina. Opting for the effective dyslipidemia treatment is essential for restoring the body’s metabolic process efficiently. Major causes of abnormal changes in lipid profile include unhealthy lifestyle and eating habits. Most of the physicians advise dietary and lifestyle modifications as the first step of an effective dyslipidemia treatment.

Hyperlipidaemia, also known as hyperlipoproteinemia is a subset of dyslipidemia. Characterised by an excess amount of lipids in the blood stream, hyperlipidaemia slows down the metabolic functions of the body. Elevated levels of fats in the blood stream speed up the plaque accumulation which further leads to narrowing of arteries. As mentioned above, the first line of defence against the risky hyperlipidemia is opting for a healthy lifestyle. However, in some cases, medications are prescribed by the physicians to treat inherited forms of risky hyperlipidemia. Correlation between hyperlipoproteinemia and coronary vascular diseases has been proved by the researchers. So it is essential to treat this critical condition as early as possible to stay away from the risk of heart disease, stroke and other health implications.

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Stroke Prevention In Atrial Fibrillation Guidelines

A normal heart beat occurs whenever there is a coordinated progression of electrical impulses. Sinoatrial node (SA node), also known as the heart’s natural pacemaker sends out the electrical impulses which will make the atrium and ventricles contract and push blood throughout the body. Any disruption to this electrical impulse generation and transmission results in symptomatic heart valve disease treatment, abnormal heart rhythms and is termed asarrhythmia. In some cases, the erratic impulses are produced by any other heart muscle in the atria that overrides the functioning of the heart’s natural pacemaker. This leads to the fibrillation of atria, further resulting in excessively higher or abnormal heart rates and the condition is termed as atrial fibrillation (AF) or AFib. Evaluating the symptoms and seeking the right atrial fibrillation treatment is essential to reduce the risks of stroke and heart failure.

Erroneous electrical signals sent from the atria leads to the disorganized contractions of heart chambers.  Irregular contraction of atria and ventricles leads to an abnormally faster heartbeat thereby reducing the heart’s efficiency and performance. Moreover, the chaotic rhythm in the atria causes disturbances in the blood flow. This sometimes leads to blood clot formation, which can travel to the brain, resulting in stroke. People with AF are at a higher risk of having embolic stroke and heart failures. That is why it is always recommended to opt for the most helpful form of right atrial fibrillation treatment.  AFib patients with higher or moderate risk of developing a blood clot are prescribed with medications, catheter-based procedures or surgery. Stroke prevention in atrial fibrillation is possible only by cutting down the chances of blood clot formation.

Depending on the level of risk and assessment of your symptoms, anticoagulant medicines are prescribed by the physicians. Vitamin K antagonists have been used as the standard therapeutic option for stroke prevention in atrial fibrillation patients. Warfarin, dabigatram, rivaroxaban and apixaban are some of the commonly used blood thinning medicines. Preventing the abnormalities in heart rate is also important for the symptomatic heart valve disease treatment. Depending on the severity of Afib episodes, underlying cardiac issues and the symptoms, the physician will determine the best risk stratification strategy.

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Aortic Valve Implantation for Valvular Heart Diseases

The human heart has four valves – mitral, tricuspid, aortic and pulmonary. The main function of these heart valves is to ensure the one-way blood flow throughout the heart’s chambers. Mitral and tricuspid valves take control of flow of blood into the ventricles. Pulmonary valves allow blood flow to the pulmonary artery. Whereas, aortic valve allows the blood flow from left ventricle to aorta - a major artery that carries oxygen-rich blood throughout the body. Flaps of the valve tissues shut and open according to the contractions of the atria and ventricles, thereby preventing the chance of backward leakage. But whenever there is damage in the valve tissues, it will affect the whole blood flow system of the heart leading to severe complications. Heart valve disease occurs due to valvular stenosis or valvular insufficiency organic and functional mitral regurgitation.

An obstruction in the blood flow to the heart due to the narrowing of valves is called valve stenosis. Tissues of the valve flaps become stiffer or thickened due to the stenosis, which further cuts down the blood supply and reduces the performance of the heart. Whenever the valve doesn’t close tightly, there will be a backflow of blood and it is known as regurgitation (valvular insufficiency). Organic and functional mitral regurgitation is a case in point. Valvular heart disease can be congenital or acquired. In most cases, the congenital valvular disease involves pulmonary or aortic valves, whereas the acquired disease involves aortic or mitral valves. Angina, shortness of breath, dizziness and excess fatigue are some of the main symptoms of valvular heart diseases. Both the stenosis and leakage issues can lead to severe cardio vascular events and complications. Advanced aortic valve implantation procedure is a preferred surgical approach to treat valve stenosis and regurgitation.

Advanced aortic valve implantation is an open heart surgery procedure during which the damaged aortic valve is removed and replaced with a prosthesis. Aortic valve balloon valvuloplasty and transcatheter aortic valve implantation (TAVI) are minimally invasive treatment alternatives available for managing valvular diseases. Even after the valve implantation, the physician will advise the patients to follow some medications. Oral anticoagulants are prescribed to prevent the risks of valve-associated thrombosis and strokes. Evidencebased vitamin k antagonist guidelines are followed by the physicians for the antithrombotic and thrombolytic therapy for patients with artificial valves.

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Treating Atrial Fibrillation with Vitamin K Antagonist Therapy

Blood to the heart muscles is supplied by the coronary arteries and the entire pumping process is controlled by the heart’s electrical conduction system. Any disruption to the electrical signal transmission affects the blood flow and functioning of the heart. Whenever there is an obstruction in the blood supply, the heart muscles become starved of oxygen and nutrients, which leads to more chest pain or discomfort.  Atrial fibrillation (AF) is one of the common heart conditions characterised with excessively higher or abnormal heart rates. Moreover, it also increases the risk of blood clots causing stroke or life-threatening congestive heart failures. That is why it is highly recommended to seek treatment for AF at the right time.

Atrial fibrillation is categorised into paroxysmal, persistent and permanent depending on the degree and frequency of AF episodes. Diagnostic tests and accurate evaluation of symptoms is essential to devise the right treatment method. Atrial fibrillation has strong associations with other serious cardiovascular diseases such as congestive heart failure, hypertension and coronary artery diseases. Treatment options for AF include medical therapy, catheter ablation and insertion of pacemaker. Drug treatment is often preferred to prevent the risk of stroke or to control the heart rhythm. Patients with permanent AF are at an increased risk of stroke and thromboembolism. Oral anticoagulation common vitamin K antagonist therapy (VKA) is the standard medication prescribed for AF patients with moderate or high risk of stroke.  Also known as blood thinners, this medication demands regular blood tests to monitor its interactions. Some of the common vitamin K antagonist therapy medications include warfarin, apixaban, dabigatran and rivaroxaban.

Catheter ablation is another procedure to treat AF, where the source of erratic signals is destroyed using high-frequency radio waves. Having an artificial atrial fibrillation pacemaker fitted below the skin near the collar bone is another option to maintain the normal heart rhythm. A pacemaker is a small device that consists of a pulse generator and lead wires. Implantation of an artificial atrial fibrillation pacemakeris a minor surgical procedure that is typically done in an electrophysiology lab. Right after the implantation, the device takes over the job of sinoatrial node (SA node) and helps the heart beat regularly. Treatment for atrial fibrillation is decided on the basis of the patient’s symptoms, underlying cause, overall health condition and other factors.

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Percutaneous Coronary Intervention in Managing Acute Coronary Syndromes

Damage of the heart muscles due to inadequate blood flow or oxygenation is known as myocardial ischemia. The condition becomes worse in some cases, resulting in myocardial infarctions (heart attacks) or unstable angina. Atherosclerotic plaque build up in the coronary arteries is the main cause of restriction in the blood supply. Termed as Coronary Artery Disease (CAD) or coronary heart disease, this condition has been a leading cause of mortality and morbidity. CAD can lead to acute coronary syndrome (ACS), a condition characterised by the signs and symptoms compatible with myocardial infarctions (MI) and unstable angina (UA). The spectrum of ACS clinical presentation covers a range from UA to non-ST-segment elevation myocardial infarction (NSTEMI) to ST-segment elevation myocardial infarction (STEMI). In a nutshell, ACS is associated with the sudden and unexpected rupture of a vulnerable plaque followed by the partial or complete blockage of a stenotic artery. Reperfusion therapy is recommended for ACS patients on an immediate basis. Aggressive medical therapy or non-invasive percutaneous coronary intervention is performed to restore the blood flow to the heart.

Either a combination of anti-ischemic and antithrombotic agents or a non-invasive percutaneous coronary intervention is preferred for treating UA and NSTEMI patients. Accurate diagnosis and prompt revascularization procedures are crucial in devising the management strategy of ACS. Guide-wire based Fractional Flow Reserve (FFR) has become an indispensable tool for the interventional procedures. In-vivo evaluation of the vulnerable plaque and the well-validated cut off value offered by  FFR measurements, guides the ACS treatment. To help choose between drug therapy and revascularization procedure, Guide-wire based fractional flow reserve helps the interventional cardiologist to make a decision.

Although PCI has bbeen considered the safest way to reduce complications related with MI and ACS, some findings reported the occurrence of cardiac arrhythmias among patients undergoing the percutaneous procedure. Irregularity in the heart beat or rhythm leads to twitching of atria and desynchronised contractions of heart chambers, thereby increasing the risk of stroke and heart failure. Insertion of a medical Atrial Fibrillation Pacemaker provides a solution to help prevent adverse clinical conditions and outcomes. Hooked up to the heart with tiny wires, an artificial medical atrial fibrillation pacemaker reduces the risk of complications. Appropriate management of arrhythmia is crucial to improve clinical outcomes.

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Barostim Therapy & Cardiovascular Health

Whenever there is an obstruction or blockage in the coronary arteries, it hinders the oxygen-rich blood flow to the heart muscles, resulting either in angina (chest pain) or myocardial infarctions (heart attacks). In some cases, the blockage occurs more slowly so that collateral circulation starts to take up the role of coronary arteries. In medical terms Coronary chronic total occlusion is defined as – “a complete blockage of the coronary artery with TIMI (Thrombolysis in Myocardial Infarction) zero flow present for an estimated duration greater than or equal to three months”. Chronic Total Occlusion (CTO) is often found in patients with significant coronary artery disease (CAD), presenting a management dilemma for interventional cardiologists.

Coronary artery chronic total occlusion which occurs due to the deposit of fibrocalcific plaque is one of the most commonly identified lesion subsets in CAD patients. Revascularization of CTO can offer varied benefits as it provides improved heart function and reduced risks of arrhythmic events. Intricate pathophysiology of organized fibrocalcific atherosclerotic plaque which makes it difficult to cross with guide –wire increases the complications of percutaneous approach for CTOs. A promising solution to this guide-wire problem was the delivery of radiofrequency energy through the catheter guide wire that can burn off the blockage. Similar to the novel latest Thermocool Smarttouch Catheter, this method allows the interventional cardiologist to ablate the atherosclerotic plaque without causing any injury to the wall of the coronary artery. As the latest Thermocool Smarttouch Catheter is mainly used during the cardiac ablation procedure, the safe-cross-guided radiofrequency total occlusion crossing system allows the physician to clear out the CTO blockage to perform percutaneous coronary intervention (PCI). 

Another risk factor that can increase the chances of major acute cardiovascular events among the CAD patients is the presence of resistant hypertension. As the name implies, it is a medical condition when the blood pressure remains stubbornly high despite medical treatment. Promising results from the novel barostim therapy presents new hope to the medical community. Reducing the excessive blood pressure and improving cardiovascular function by a great extent, barostim neo implantation and therapy is projected to be an ideal choice for treating resistant hypertension. Novel barostim therapy can reduce the likelihood of adverse cardiovascular events thereby improving the quality of life. 

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Stenting For Multivessel Coronary Artery Disease

Hardening of arteries (atherosclerosis) not only causes lesions in the blood vessels but also results in the obstruction of blood supply to the heart muscles. During strenuousactivities, narrowed coronary arteries won’t be able to supply enough blood to the myocardium leading to angina (chest pain). Coronary artery disease (CAD) can be fatal as it is a major cause of heart attacks (myocardial infarction). CAD  can also lead to disability and decreased quality of life. Managing coronary heart disease has always been a challenge to cardiologists due to the increasing complexity of lesions and location of stenosis. Symptomatic Multivessel coronary artery disease that affects two or more epicardial vessels is a case in point. Optical therapeutic approach for treating multivessel disease (MVD) is still a point of fervent discussion within the medical community.

There are mainly three treatment modalities available for patients with MVD which includes medical therapy, non-invasive percutaneous coronary intervention (PCI)and coronary artery bypass graft (CABG) surgery. Though bypass surgery was a preferred approach over stenting in MVD treatment, the recent advancements in catheterization procedures and technologies have reignited an interest in percutaneous intervention. Drug eluting stenting (DES) has proven successful in overcoming the adverse clinical outcomes of bare metal stenting (BMS) by a greater extent.  Moreover, widespread application of fractional flow reserve measurement technique has made it easier for physicians to choose between the non-invasive percutaneous coronary intervention and pharmaceutical treatment for a CAD patient. As per the famous FAME study, it has been proved that FFR guided percutaneous approach can ensure better outcomes in managing the symptomatic multivessel coronary disease. Followed by that, the FAME 2 study results demonstrated PCI along with medical therapy can ensure better outcomes when compared to medical therapy alone.

Innovative advancements in the cath lab set up and interventional environments have been helping physicians to perform both interventional and surgical procedures with great accuracy and precision. For example, Philip’sXper Flex Cardio equipped with multiple functionalities aids physicians in treatment decisions. This hemodynamic cardiac monitoring system supports FFR measurements and provides 16-lead ECG analysis, culprit Artery detection and patented ST maps. Philip’s Xper Flex Cardio system and similar physiomonitoring systems can surely enhance the efficiency on multiple levels.

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FFR-Guided Percutaneous Coronary Intervention Gain Advantage Over Medical Therapy

Coronary heart disease also known as ischemic heart disease can be described as a condition where the coronary arteries are severely narrowed because of atherosclerosis. When the heart muscle is starved of oxygen and nutrients, it induces chest pain (angina). However, in some cases there is a complete blockage in blood supply leading to heart muscle damage and myocardial infarctions (heart attacks). Some of the common symptoms of coronary artery disease (CAD) to watch out for include chest pain, nausea, dizziness and shortness of breath. It is advisable to seek medical treatment immediately before the symptoms turn severe and frequent. Remarkable advances in the diagnostic procedures, standard blood flow measurement techniques and medical imaging devices have been helping cardiologists to evaluate CAD in a better way.

Angiography is the first-line diagnostic investigation recommended by cardiologists. Having a detailed physiological analysis of stenosis in the arteries is essential to choose between the varied treatment options – pharmaceutical therapy, FFR-guided percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery.  However, several studies and clinical trials have pointed out the limitations of coronary angiography in estimating the degree of luminal narrowing. Standard blood flow measurement techniques and imaging tools can provide a detailed visualization of the blood flow and performance of the heart.  Fractional Flow Reserve (FFR), as a case in point, assists the physicians in identifying the ischemic and non-ischemic lesions. Results published by the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study demonstrated the superiority of FFR over angiography in deciding whether or not to stent the lesions. Moreover, it has been proved that FFR-guided percutaneous coronary intervention assure better outcomes and significantly lower complication rates.

Medical therapy was considered to be the best approach for patients with stable CAD and significant stenosis. Results from the latest FAME 2 trials conclude that FFR-guided drug-eluting stenting (PCI) is superior to medical therapy for managing stable coronary disease. Two year data from FAME 2 trials shows a great reduction in the major adverse cardiac events and decrease in the risk of urgent revascularization. As per the latest FAME 2 study results, FFR-guided PCI plus optimal medical therapy shows sustained clinical and economic benefits when compared with medical therapy alone.

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Treatment of Coronary Bifurcation Lesions

Interventional cardiology has been witnessing technological advances and improved success over the last decade. Increasing success and safety levels of interventional cardiac procedures has improved the outcomes for patients with coronary artery disease (CAD). An underlying pathologic process called atherosclerosis can make the coronary arteries lose their flexibility and elasticity over time. Plaque build-up causes the artery to narrow thereby impairing the blood flow to the heart tissues. One of the common coronary heart disease symptoms is chest pain or discomfort accompanied by shortness of breath. In most cases, the pain may occur during physical or emotional stress. Early diagnosis and treatment is the best way to tackle heart disease and live a quality life. That is why it is often advised to seek immediate medical attention when faced with common coronary heart disease symptoms.

Advanced diagnostic techniques and therapeutic approaches are available for detecting and treating CAD conditions. Percutaneous coronary intervention (PCI) with its minimally invasive procedure and reduced complication rate has superseded Coronary Artery bypass Grafting (CABG) in the treatment of single vessel CAD. Despite the advancements in stent technology and catheterization tools, interventional cardiologists find it a challenge to treat some complex coronary lesions that are often associated with higher restenosis, worse outcomes and greater complication rates. Complex bifurcation lesions are a case in point. When defined in medical terms, coronary bifurcation lesions can be defined as – “a lesion ≥50% diameter stenosis involving a main branch and/or contiguous side branch with a diameter of ≥2.5 mm”. Around 15% to 20% of the CAD lesions are bifurcation lesions, which present a challenge to interventional cardiologists.  Even though coronary angiography is considered as the gold standard for diagnosing heart ailments, angiographic evaluation alone can’t provide substantial information about the stenosis.

Innatelimitations of coronary angiography were a major concern in devising a right risk stratification approach for the complex lesions. Moreover, plain balloon angioplasty and bare metal stenting results were suboptimal because of the high rates of restenosis. But with the introduction of fractional flow measurement, advanced medical imaging methods and bioabsorbable drug eluting stent technology, percutaneous treatment of complex bifurcation lesions seems possible. Several studies and clinical trials are going on with the objective to address concerns related to stenting, and will hopefully hold the key to the successful treatment of bifurcations.

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Fractional Flow Reserve Measurement For Assessing Coronary Stenosis

Coronary Heart Disease which occurs as a result of atherosclerotic plaque-build up in the inner walls of coronary arteries is a common heart ailment that has been affecting millions of people worldwide. The field of cardiac science and interventional cardiology has been striving hard to devise an optimal approach to manage coronary artery disease (CAD).  Evaluating the physiological significance and severity of lesions is a challenging factor in most cases which is why pressure-based Fractional Flow Reserve measurement method was introduced. FFR provides a well-validated index in deciding between coronary stenting and medical therapy. Thses days, it is considered an indispensable clinical tool in the catheterization laboratory.

Pressure-based Fractional Flow reserve measurement provides the ratio of normal blood flow to the maximum achievable blood flow in the same coronary artery, given the maximal vasodilated condition. Lesions that measure a FFR value of less than 0.75 need percutaneous coronary intervention (PCI) with stenting, while lesions of a value higher than 0.75 should be managed with pharmacological treatment. Minimally invasive FFR technique possesses several special features that make it a gold standard for diagnosis in the catheterization laboratory. A well-defined cut-off value, unequivocally normal value for every patient and narrow gray zone are some of the major characteristics. Fluoroscopy guided pullback pressure recording performed during the catheterization proves to be a great tool in obtaining detailed spatial information and evaluating the hemodynamic effect of stenoses. The sensor placed in the distal coronary artery during FFR procedure is simply pulled back under fluoroscopic guidance to measure the pressure levels across the blood vessel. Helping the interventional cardiologist to assess the extent of lesions and exact location of the pressure drop, fluoroscopy guided pullback pressure recording proves to be a great diagnostic tool for different patient subsets.

Bifurcation lesions that involve the proximal main vessel, the distal main vessel and the side branch are one of the most challenging lesion subsets. Associated with restenosis, greater complications and lower success rates, severe coronary artery bifurcation lesions pose a major challenge for the interventional cardiologists. PCI is not considered as a favourable approach to treat the symptomatic coronary artery bifurcation lesions. However, with the advent of fractional flow reserve method and pullback pressure measurements, FFR guided PCI assures excellent results and safer outcomes.

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Left Main Coronary Artery Stenting – Is it a Safe Approach?

Common coronary heart disease (CHD) also to referred as ischemic heart disease is the leading cause of heart attacks and angina. Atherosclerotic plaque build-up in the inner walls of coronary arteries hardens the blood vessels and restricts the blood supply to heart. Lack of oxygen leads to the damage or death of heart tissues which results in ischemia. Clots in the arteries can be life-threatening, as it eventually restricts or completely cuts off the oxygen-rich blood supply resulting in angina or myocardial infarctions (heart attacks). Some of the common coronary heart disease symptoms include sharp pain or pressure in the chest that travels to the arms and jaw, shortness of breath, light-headedness and fatigue. Even if the symptoms are mild, seeking immediate medical attention is necessary.

The left main coronary artery (LMCA) is responsible for supplying blood to a large segment of the myocardium and stenosis of LMCA will lead to acute cardiac events. Coronary Artery Bypass Graft (CABG) has been considered the standard therapeutic option for treating left main coronary artery disease (LMD), because it provides better survival rates when compared to drug therapy. Percutaneous coronary intervention (PCI) with bare metal stents tended to result in in-stent restenosis and a need for revascularization, making it a risky choice. But with the advent of state-of-the-art catheterization technologies, drug-eluting stents and antithrombotic agents, newer left main coronary artery stenting has made it a viable option for patients with high surgical risks or co-morbidities.

Ongoing clinical trials and research studies have been evaluating the effectiveness of using drug-eluting stents (DES) for Unprotected LMCA compared with CABG. Targeted lesion revascularization advantages of minimally invasive newer left main coronary artery stenting can be considered as a safe and effective alternative to CABG, especially for patients in a high-risk group. Even though DES is considered as a great step in interventional cardiology, concerns over the polymer-associated complications and risk of thrombosis have raised questions about its safety. Drug-eluting stent thrombosis is closely associated with acute myocardial infarction resulting in mortality and morbidity. Biocompatible and bioabsorbable stents that are developed in order to overcome issues such as drug-eluting stent thrombosis is a recent development in the interventional community that offers a promising approach for PCI in treating left main coronary artery disease. But in the meantime, cardiologists have to choose either PCI or CABG to manage the left main disease based on the SYNTAX score and medical-surgical consultation. 

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Advanced Diagnostic & Treatment Options for Cardiac Artery Disease Management

Stress testing is a widely used non-invasive diagnostic method that provides reliable information about the severity of symptomatic cardiac artery disease or coronary artery disease (CAD). As the name indicates, stress testing is carried out by putting the body under physical stress. A myocardial perfusion scan is a combined procedure that combines stress testing and a nuclear heart scan.

Myocardial perfusion scan is a non-invasive cardiac imaging method that is performed during rest and stress. For the stress testing, patients are injected with a radioactive tracer during the exercise (running on a treadmill). Radionuclide which circulates through the blood stream will show the possible damages and blockages present in the heart muscle. During the stress testing, the patient will be continuously monitored by keeping track of heart rate, blood pressure and ECG changes. Pharmacologically-induced stress testing is opted in some cases, when the patients can’t exercise on a treadmill due to medical conditions. Medications are injected to make the coronary arteries dilate and promote vasodilatation. Non-invasive adenosine myocardial perfusion is a case in point. A resting scan will be performed after some hours to compare the heart functioning and blood flow. The risk of this diagnostic procedure is often associated with the stress part of the test which may lead to rare instances of adverse cardiac events. 

When it comes to cardiac or coronary artery disease treatment, percutaneous coronary intervention or PCI (angioplasty and stenting) and coronary artery bypass graft (CABG) surgery are the standard options. Cardiologists rely on the catheterization lab results and reports to devise the right treatment plan. With tremendous advancements in the interventional and catheterization procedures, PCI has gained wide interest among the medical community. Not only it is not as aggressive as CABG, but it also cuts down the recovery time and treatment costs. 

The novel idea of fully degradable bioresorbable stents that can overcome the major limitations of bare metal stenting (BMS) and drug-eluting stenting (DES) has also been fascinating the interventional community from a long time. Bioresorbable or bioabsorbable stents are supposed to improve the endothelium function during a critical period. When no longer needed, it will be bioabsorbed to the body thereby negating the risks of thrombosis and the need for antiplatelets therapy. Clinical trials and experiments are still going on and until then drug eluting stents and bypass surgery remain the preferred revascularization procedures.

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