Though a tad expensive, the treatment for heart ailments caused by narrowing of arteries is no more a difficult task
IT is believed that the coronary artery disease (CAD) is the leading cause of death worldwide. The CAD, along with cerebrovascular diseases (CVD), accounts for little over 25 per cent of all deaths in adult population. It is estimated that heart attacks, caused by diseases like the CAD, kill more people than cancer and road accidents put together.
Treatment modalities for the CAD, commonly manifested as heart attack and angina, have undergone phenomenal changes over the past three decades. Once the only available remedy was medicines; then came surgery; and of late the interventions are playing an important role. Thus today we have three established modalities to treat the CAD, namely medical, surgical (coronary artery bypass graft surgery) and interventional, called percutaneous transluminal coronary angioplasty (PTCA), with or without stenting. These procedures are now collectively called the percutaneous coronary intervention (PCI).
The choice of each modality depends upon the patient’s clinical profile (symptoms), severity and nature of arterial lesions, (anatomy of the lesions), availability of facilities and the required expertise in the field. Additional factor is the preference of the patient to a particular modality. All these modalities are complementary to each other and can be used alone or in a certain combination. Pharmacotherapy and lifestyle modifications, however, remain their basic ingredients.
The PCI has, over a period of 15 years, undergone tremendous advancement. The treatment starts with simple dilation (widening) of the narrowed (stenosed) coronary arteries with balloons (ballooned angioplasty) by applying controlled atmospheric pressures through an external device. Then the balloons are passed over a fine wire. This procedure does open up narrowed arteries but carries several complications and risks.
In this regard, it has also been reported that a large number of patients complained about recurrence of the disease after successful initial dilation of their arteries due to recoiling of the inflated segment (restenonsis); some others developed dissection at the pressure area with serious consequences. Simple balloon angioplasty is, therefore, technically difficult, risky and not a very successful modality.
However, the situation has now been revolutionized with the advent of metallic stents. Stent implantation has reduced the rate of complications and restenosis significantly. This has also made the procedure technically less difficult. But it has definitely added to the cost of the treatment.
Looking at the marvellous results and low restenosis rates following the stent implantation, the high cost can be justified given the serious nature of the disease. In the span of 10 years, the stent technology has brought about extraordinary improvements. Initially, these stents were available in unmounted form and had to be manually mounted onto the balloon. This required a great deal of expertise and carried in-built complications. Fortunately, unmounted stents were shortly followed by mounted stents. These stents have gone through consistent improvement in their design and application. The new stents are easy to deploy and are more safe. Also, they have proved to be more durable.
Despite all such advancements, there are considerable chances of restenosis. Also, some of the difficult and long lesions cannot be operated successfully with these conventional stents. These problems have been overcome by the advent of drug eluting stents, which are supposed to minimize the chances of restenosis and are suitable for difficult and long lesions. However, drug eluting stents are nearly three times more expensive than the standard stents. The additional cost, therefore, remains a crucial issue.
In addition to the improvements and innovations in wires, balloons, stents and other hardware used in the PCI, the introduction of new antiplatelet agents has made another remarkable impact on the overall success of interventional procedures by reducing the immediate periprocedure as well as long term thrombotic complications.
Platelet adhesions over the angioplastied and stented surface of the artery play a pivotal role in clot formation and subsequent narrowing after successful dilation and stent implantation, particularly when the PCI is used as an emergency procedure.
The use of potent and quick acting antiplatelet agents like clopidogrel and Gp.IIb IIIa inhibitors in addition to theantiplatelet agent aspirin has now made difficult and emergency angioplasties much more safer and successful by inhibiting platelet aggregation and clot formation. Some of these agents are used prior to and during the procedure, while aspirin and clopidogrel is used on a long-term basis afterwards.
With the growing expertise in the field of interventional cardiology and with the introduction of new stents, effective antiplatelet and antithrombotic agents (PCI) are fast becoming the most popular modality in managing various subsets of ischaemic heart diseases throughout the world.
Having said that, the cost of the PCI remains an important limiting factor in its wider application in developing countries like Pakistan. It is hoped that economical versions of various items, particularly stents used in the PCI, would be introduced by the manufacturers and importers for the benefit of the common man. The government can provide significant relief by making the import of these items duty-free by removing other obstacles to their availability.
It would be worth mentioning that interventional cardiology has developed with a remarkable speed in Pakistan. Today at least 16 centres are performing these procedures regularly all over the country, out which seven are located in Karachi alone.
As IHD incidence rises in our country, the interventional cardiology will play a very important role in years to come. The people associated with medicine in Pakistan have to keep abreast of the new advancements in the field. They also have a responsibility to make these procedures cost effective so that the under-privileged class of patients can benefit from this remarkable therapeutic modality.
It is also satisfying to note that patients show their confidence in Pakistani physicians as far as these sophisticated procedures go. Not too long ago, people used to travel to the West to receive such treatments. The development of interventional cardiology in Pakistan has helped the nation save valuable foreign exchange and the botheration of travelling abroad.
Once stethoscope was considered the cardiologist’s only tool. Now cardiologists have to learn other ways and means of using wires, tubes, balloons and stents much like plumbers. Thanks to the interventional procedures, cardiology is no more a white collar specialty. It now involves a great deal of manual skill and physical work apart from mental exercise.
Though a tad expensive, the treatment for heart ailments caused by narrowing of arteries is no more a difficult task 
