By Dr Praveen Chandra
Mahesh Gupta, 45, was rushed to hospital when he complained of shortness of breath and chest pain after his workout. The diagnosis was something he had suspected all along, a heart attack, with an 80% blockage in one of the major arteries. While prompt care and advanced treatment may have saved Mahesh from further complications, it also reminded him of the fateful day his father suffered a traumatic heart attack years ago. For Mahesh, despite the severe blockage, doctors used advanced technology to guide the placement of a stent in his artery. He couldn’t help remembering that his father’s operation had led to another operation a year after the first one. Although Mahesh and his father both suffered from severe heart blockage, the treatment strategy and care he received made all the difference.
Cases like this are not just isolated episodes, but are a major cause of morbidity in our country and around the world. Coronary artery disease (CAD) is caused by fatty deposits or plaque buildup in the coronary arteries leading to insufficient blood flow to the heart. Partial blockage causes symptoms such as chest pain but, if left untreated, can lead to life-threatening complications such as acute coronary syndrome (ACS) and heart attacks (myocardial infarction). While minimally invasive procedures such as angioplasty and stent placement have long been established as the standard of CAD care, corrective therapies have since improved dramatically. Today, when a cardiac patient enters a hospital, cardiac care can be optimized by functional assessment techniques such as fractional flow reserve (FFR) and intracoronary imaging techniques such as optical coherence tomography (OCT). Not only are they examples of innovative advances that medicine has to offer, but they also pave the way for more patient-centric and quality-driven outcomes. Let’s understand the role they play, and why they need to be widely adopted for better cardiac care.
How does PCI optimization ensure a better level of care?
Percutaneous coronary intervention (PCI) or coronary angioplasty forms the basis of minimally invasive care for coronary artery disease and has remained the standard for several decades. Inserting a balloon or stent through a small incision under the guidance of coronary angiography (X-rays to visualize the heart’s blood vessels) into the blocked area of the coronary artery helps expand the area and improve the flow of oxygenated blood. One of the most pressing concerns with PCI is the limitation of imaging, which often makes it difficult to accurately identify the size of the blockage in complex cases, which in turn impacts the results of the stent. Over-stenting or inaccurate placement of stents leads to an increased risk of complications.
Fortunately, modern medicine today has provided us with improved technology that helps optimize treatment. These include techniques such as FFR and OCT which are considered the gold standard for cardiac intervention. FFR measures the ratio of peak blood flow in a narrowed or stenotic artery to normal blood flow, while the use of intracoronary imaging techniques such as OCT improves PCI procedures and treatment outcomes. FFR allows the interventional cardiologist to decide the physiological significance of the lesion (whether it obstructs blood flow and can potentially cause myocardial infarction) and whether it should be stented or managed with medication.
OCT can be used before PCI to visualize the lesion and optimize treatment accordingly or after PCI assess the failure mechanisms of the stent after deployment. OCT uses infrared light and provides intracoronary images with almost 10 times higher resolution. It helps optimize PCI by assessing stent size, placement, and expansion, identifying acute stent-related complications (e.g., stent malposition, tissue protrusion), and evaluating reasons for stent failure (eg, thrombosis or under-expansion of the stent).
More recently, FFR and OCT are available in an integrated system to further facilitate physiological, visual and diagnostic support for optimizing PCI. Clinicians attest that the personalized configuration of both allows interventional cardiologists to proactively assess avoidable stents or inaccurate placement, reducing the risk of complications and providing them with advanced information for proper diagnosis and treatment of CAD.
Advances in technology can help doctors treat patients better
The care offered by an interventional cardiologist or cardiac surgeon is closely related to the quality and availability of treatment methods. Along with the fundamentals of healthy diet and proper exercise, optimal treatment is the goal of any continuum of cardiac care. It is important for physicians to equip themselves with cutting-edge technology to provide the best possible care to their patients. These advanced techniques also help extend specialized cardiac care to vulnerable patient groups such as the elderly with coronary artery disease for whom PCI is typically deferred due to the increased risk of complications.
The integration of technologies such as OCT and FFR into cardiac care has been clinically proven to improve treatment outcomes. Better patient outcomes were observed in patients with multivascular blockages involved in the Fractional Flow Reserve vs. Angiography in a Multivessel Evaluation (FAME), now well cited and one year in duration. FFR-guided PCI has resulted in a reduced risk of heart attacks, repeat procedures, and even death. Similarly, the CLI-OPCI (Centro per la Lotta control l’Infarto–Optimisation of Percutaneous Coronary Intervention) study confirmed the clinical utility of OCT over angiography, where the former was able to detect deployment non-optimal stent in nearly 33% of cases. OCT-guided PCI improves treatment outcomes because improper stent placement leads to an increased incidence of major adverse cardiac events (MACE).
Advancements make CAD procedures more patient-centric
CAD is one of the leading causes of death and disability in our country. It is essential to understand that in the absence of a single treatment modality, personalization of therapy according to the needs of the patient is the future of this field. The availability of newer and better technologies such as FFR and OCT allows clinicians to more comprehensively assess their patients and advise them on the appropriate course of action. Overall, they improve pre-treatment assessment, avoid unnecessary procedures, and decrease the risk of complications. When implemented with appropriate lifestyle changes and medications, these tools ensure that whether it is a young patient with stable coronary artery disease or a vulnerable elderly person with a history of heart problems, excellent heart care is available to all. Ultimately, optimizing these treatment processes improves standards of care and reduces overall healthcare costs.
Dr. Praveen Chandra, Chair – Cardiac Interventional and Structural Cardiology, Interventional Cardiology, Medanta Heart Institute
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