Hearty Questions

Q. What is “Balloon Angioplasty” ? Does it replace “By Pass” surgery ?
A. When there is a localized narrowing in the early segment of one or more of the coronary arterial pipelines, a new method of dealing with this has developed. It consists of dilating the narrow segment and distending it from its lumen side with the help of a pressure balloon pump. The force used is of a fair amount. If successful, the narrowed segment becomes wider so that more oxygenated blood is able to flow through the pipeline and is thus able to supply the heart muscle with adequate blood containing oxygen and other nutrients. The heart muscle becomes more healthy and the disabling symptom of angina is relieved. Thus, the method of “balloon-pump”, in principle, appears simple and effective. It has, however, several limitations. There can be complications such as the detachment of a clot or immediate re blocking of the distended segment by a fresh blood clot because the area under distension becomes raw and rough. In fact, in some patients, immediate “by-pass” surgery is required. The surgical team and surgical theater is therefore kept ready as a rule, so that an emergency by-pass surgery can be performed immediately, should it become necessary. Even in those patients, who are lucky enough to go through the initial procedure successfully, there is an annoying rate of relapse.

Q. I am staying on the second floor of an old building where there is no elevator. Can I climb upstairs after my heart attack ?
A. Yes, after about two months of a heart attack you can climb up provided there is no residual complication such as cardiac failure. Try to climb somewhat slowly — but certainly not like a sick man. Whenever you feel out of breath, wait for a while before you resume a further upward climb. You need to pause only for a short time, of about two minutes, whenever you get unduly breathless. To start with, climb up once every day. After about one month, you can do the same twice a day or even thrice, if the situation so demands. The only precautions required are not to rush up like a young boy of twenty and not to climb up on a full stomach. Climbing up should be so timed that you are on an empty stomach. Climbing down the stairs is no exertion for the heart.
In case you suffer from angina while exerting, it would be better to put a pill of nitroglycerine or isosorbide in your mouth and continue sucking it while climbing up. Some elderly persons do suffer from a sudden fall in blood pressure after this pill and may complain of a fainting sensation. Should this happen, it would be safer to avoid use of this pill while in the upright posture, particularly the standing posture. In such a situation, the elderly patient with angina would require to pause for a few minutes as soon as the angina pains come on.

Exercise For Heart Ailment
Q. What is this “exercise prescription” that we read about as a method of curing heart ailment ?
A. In the first instance, exercise cannot cure a heart ailment. Exercise trains the heart of a patient to endure certain physical workload so that a patient need not think that his heart is not capable of withstanding any physical exertion. By gradual training, the heart can be made capable. However, so far there is nothing to suggest that it has a curative value in the sense that it can make your heart stronger than before or that it would open up new collateral coronary channels.
At the same time, however, the beneficial value of exercise cannot be underrated. Exercise, in moderation, which makes you feel pleasantly tired, is certainly good. It tones up the body and makes you feel younger and fitter. The energy-levels, stamina and self-confidence are enhanced. Nature has provided us with legs which are meant for walking. They must be used, as we use all the other parts of the body.
The question comes up as to how much to use them ? The rational answer would be to use them well without getting too tired or fatigued. At the same time, do not try to be an over enthusiastic “muscle-man”. If you overdo any exercises, you will land up, in fact, precipitating a fresh heart attack, cardiac failure etc. Similarly, in a patient who has already got cardiac failure, exercise will weaken the heart further. Realizing the limitations and benefits of exercise, please settle down to strike a healthy balance.

Q. Are there any clot dissolving agents now available which can effectively remove the blocking of the clot in the heart artery ?
A. Yes. These are known as “Thrombolytic agents” and sold under the name of urokinase, T-pa, Streptokinase etc. These powerful agents unfortunately can work only if given within the first 4 hours of acute thrombosis. They are very expensive and are supposed to work more in Anterior infarction. Their use in Inferior infarction is controversial. These strong drugs can be given only in a hospital where good facilities are available. The big question in our country is that how many patients can reach such a well equipped unit in first 4 hours of the attack symptoms ? (Not from the time of diagnosis but from the time of major or severe symptoms.) In western countries, the service of a helicopter is therefore introduced.
These drugs are not effective in severe angina or unstable angina because the mechanism here is not thrombus clot blockade but the aggregation of platelets in the main. But the side effects of these drugs can be heavy and serious. They are — reperfusion arrhythmias, bleeding in the brain or any other body organs and reocclusion which can occur in about 40% of patients.

Q. What is coronary angiography after a heart attack ?
A. The test of coronary angiography should not be taken lightly. It is an invasive test and does create complications even in the best heart centers allover the world. The potential risk is admittedly small, but it should be justifiable. A catheter tube is passed inside the coronary arteries and in the heart chambers, and a radio-opaque dye is injected in order to visualize the structural disease of the coronary arteries and study the function of the heart chambers. It is not a pleasant procedure. This method of study does not help much in arriving at the medical diagnosis or in outlining future medical treatment.
It is required if “by-pass” or “balloon” surgical treatment is contemplated, as a better alternative, for a given patient. The patient, at the same time, should also be willing to accept to undergo surgical treatment, should there be an indication after angiography study. If the patient is unwilling to undergo a major surgery within six months or so, it is of no use to a physician for planning the medical line of treatment for his patient. In such a situation, this procedure, with its potential risk, though minimal, is uncalled for. It only becomes an academic exercise with no ultimate benefit to the patient.

Q. Can a patient, who has developed left ventricular failure or congestive cardiac failure, be helped by coronary “by-pass” surgery ?
A. No, the established case of cardiac failure cannot be helped by this form of surgery. The heart muscle has already become weak and certain fibrotic changes have developed in the muscle which cannot be rejuvenated. In a few patients, there is what is known as ventricular aneurysm (bulge) which contributes greatly to cardiac failure. The aneurysm can be removed by surgical means and this type of surgery can be of great help. This operation, no doubt, carries significant risk by itself. However, it can be thought of in an intractable case of cardiac failure. The diagnosis of aneurysm can be reasonably and safely made by nuclear cardiac study and by two dimensional echocardiographic study.