Angina: treatment options
What is angina?
Angina, by definition, is a chest pain usually related to exertion. It is caused by, in 99% of cases, a narrowing of the coronary arteries – the arteries supplying the heart muscle [with oxygen].
This usually develops either due to smoking, due to high cholesterol, or bad diet or bad genes, as it can be hereditary.
People with angina usually present to me with tightness in the chest.
Some people have shortness of breath instead of chest pain. In general, we try to make the diagnosis, either by putting patients on a treadmill to reproduce the symptoms they have when they exercise, or we can do other tests, such as an MRI scan or a stress echo. The latter helps show whether they have a lack of blood supply to the heart or if the heart is not coping well.
The gold standard of discovering if a patient has coronary disease is with an angiogram; this could be invasive or with a CT scan.
The next step is to treat the patient with medication. Ideally, we would try to improve the prognosis by giving aspirin and reducing cholesterol. These prevent future heart attacks but do not help the symptoms. We have several medications we give in a stepwise fashion to treat the symptoms.
The medications we give work in various ways, and we use a combination so that we reduce the workload of the heart or open the arteries to improve blood supply.
If we are convinced that the patient has angina, but the medication has cleared the symptoms, we often arrange a CT coronary angiogram to make sure the patient does not have 'prognostic' disease - a narrowing at a place where if it blocked it could cause serious damage, or death.
This scan is a normal CT scan used for brain scans, but now we can look at the heart too. This is a non-invasive test; we inject a dye at the back of the hand, and we can reconstruct the coronary arteries, which gives us a reasonable idea of what is going on. It is not a 100% accurate, so it is not quite as good as doing an invasive angiogram, but this is non-invasive and a 10-minute test.
The gold standard treatment is an invasive angiogram, which is where we can look to inject dye specifically into the coronary arteries, usually from the wrist, using the wrist’s radial artery. We pass a tube up to the heart and inject the dye into the coronary arteries, which allows us to see where there is any narrowing.
We decide to go for an invasive angiogram if the CT was not clear (or if we cannot do a CT scan because the heart rate is too fast), but more importantly if the medication has not cleared the angina and we want to see whether we need to treat the narrowing(s).
During an invasive angiogram, we have several decisions to make. We can measure how important the narrowing is by inserting a pressure wire, which measures the pressure drop across the narrowing. We can undertake an ultrasound of the narrowing, and we can do something called an OCT, optical coherence tomography. The latter is a laser inside the coronary arteries, to help us see the texture of the narrowing and how significant it is, as well as how much calcium, cholesterol deposits, or even different types of clot.
The advantage of this invasive procedure is that we can put a wire through the narrowing and open it up and put a stent in – a wire mesh to open the heart.
If a patient’s narrowing is calcified and is very tough to open, we can break up the calcium and we have two techniques we can use. One is rotablation, which is otherwise termed rotational atherectomy. This is basically a diamond drill, which drills through the calcium to open the arteries.
We can also do an intracoronary lithotripsy, or ICL. This is also called shockwave treatment, which breaks up the calcium and allows us to insert a stent. It is similar to the technique used to break up kidney stones. Sometimes we cannot modify the calcium enough – for example, sometimes a stent will not open enough it is likely to block up.
Angioplasty is a day case procedure; it usually takes anything from 15 minutes to four hours; it depends how difficult it is. Usually the patient is awake, but we can give them some sedation if they feel anxious, and they can often listen to music as we do the procedure.
At the end of the procedure, we put a little band on (where we made the 2mm nick in the artery) to prevent bleeding. The patient would generally be allowed to go home around two to four hours after the procedure. If the procedure was through the wrist, the patient can sit up straight after, but if it was done from the grain, they would have to stay flat until we are confident that there is no bleeding.
When our patients go home, we’ll tell them we’d like them to stay with someone overnight - just in case they start bleeding. This is rare, as we make sure everything is fine before they leave hospital.
If they only had an angiogram, they may be able to go back to normality the next day; they can drive, too.
If they have had an angioplasty, we will tell them not to drive for a week and that’s what the DVLA advises.
Generally, the patient will gradually start improving. If they were having chest pain symptoms, they may find they benefit straight away, but sometimes the benefit may be in a few days’ time or a few weeks, even.
I will see then them in the clinic around two to four weeks later, depending on how complicated the procedure was. I may do another ECG to see how the heart is coping, and whether there are any changes, and then generally follow up to see if there is any damage to the heart. If everything has settled, depending on how the patient is feeling, we generally discharge them back to their GP.