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STEEL HEART

Angioplasty with stents offers good-and fast-results for patients with coronary-artery disease

By Sheila Lynn Molarto, Contributing Writer

Today, patients with coronary heart disease need not have their chests opened to unblock blood vessels
and to get the heart working well again. Now, all it takes is a small puncture near the groin, balloons, fine
wires, X-ray, and flexible steel mesh tubes-or stents, which are no bigger than an ordinary pen.
Bypass surgery has been the most common form of therapy for coronary-artery disease (CAD) since
the late 1970s. In the next decade, percutaneous transluminal coronary angioplasty was introduced, using
only balloons to restore the patency of the artery.
Though many would opt to have a bypass, angioplasties with stents are also getting more common in
the Philippines, says Dr. Edwin Dizon, an interventional cardiologist from the Cardinal Santos Medical
Center and Philippine Heart Center (PHC). Angioplasty is recommended for single- and double-vessel
disease. On the other hand, a bypass is more appropriate if three coronary arteries are affected. "But
there are some patients who would not want to undergo a major surgery, so they usually request for a
multi-vessel angioplasty" he adds.
For Cecille Pelayo, professor and head of the Law and Tax department of the University of the East in
Caloocan, angioplasty was the best option. She just had three stents placed in her heart in February this
year at PHC. Busy with her teaching workload and other social activities, she had stopped exercising and
neglected her diet. Six months prior to her operation, she started having chest heaviness, easy
fatigability, and shortness of breath. When Dizon found three blocked arteries and recommended an
open-heart surgery, she hesitated, fearing the complications of such a major procedure. Not wanting to
take any chances, she immediately decided to undergo angioplasty.

Balloons and wires


Patients who undergo angioplasty are usually those with new-onset angina, or with a history of chronic
chest pains, but asymptomatic when maintained on medications. One who is about to undergo a major
surgery, but has a history of CAD, could also have an angioplasty to lower the risk of having a heart
attack during surgery. "The other subset of patients are those admitted at the emergency room, who are
having an evolving heart attack or unstable angina," Dizon notes.
After the necessary screening procedures, such as treadmill stress and thallium test, and coronary
angiogram, the angioplasty can be done. From the femoral artery near the groin, the surgeon inserts the
catheter, then a guidewire with a deflated balloon at the end, then guides it to the narrowed vessels, with
the help of X-rays. After the balloon is gently inflated to restore normal blood flow, the stent will be
positioned in the redilated part of the artery. The stent then expands to further reinforce the artery.
The whole procedure, done under local anesthesia, usually takes less than an hour. If there are no
complications, the patient is sent home the following day, after a maximum of 24 hours in the intensive-
care unit (ICU). "In Japan, after an angioplasty in the morning, the patient can go home in the afternoon,"
narrates Dizon. Surgeons there insert smaller catheters from an incision on the wrist.
Stents have two types: the bare metal and medicated stents. The former is cheaper, priced between
PhP40,000 to PhP60,000 each, and are usually placed in large blood vessels.
The catch is, rates of restenosis in bare metal stents are higher. "You may have to repeat the
procedure in 20 to 30 of 100 patients within the next six months," Dizon explains.
Meanwhile, medicated stents could cost from PhP110,000 to PhP150,000 each, depending on the
hospital. This stent has a medicine on the surface, which prevents the formation of scars inside the artery
that could eventually block smooth blood flow. Only three to eight percent of patients who had medicated
stents have restenosis. The whole surgery could cost up to PhP700,000, depending on the number of
stents used.

Fast-tracked angioplasty
In less than an hour, Pelayo's heart is as good as new. She was awake during the whole procedure
and even watched the monitor. "It's just like having an angiogram," she says. Later in the ICU, she started
sending text messages to all her friends that she had just come out of surgery. "When friends visited me
in the ward, I was on a chair chatting with them, and not lying on the bed as they expected," she shares.
Now that there's marked improvement in her health, Pelayo is not taking anything for granted, though
she may have some difficulty adjusting to some limits in activity and diet, with a drastic lifestyle overhaul
in the works. Three months from now, if there are no complications, she will resume her normal routine,
which includes ballroom dancing. For now, she takes it easy as she goes about her classes.
After the surgery, aspirin and other drugs are given for 15 to 30 days to prevent clots. Unlike bypass
patients who have a recovery period of six to eight weeks, most angioplasty patients can work after a
week. Yet Dizon cautions his patients to first avoid vigorous activities, such as jogging, to prevent
hematoma of the puncture site at the femoral area.
"The success rate is usually more than 90 percent, except for totally occluded lesions," Dizon says.
"Experience of the surgeon counts, as angioplasty is a highly technical procedure."
Besides angioplasty, Pelayo believes that divine providence saved her from the wrath of heart disease
that claimed the lives of her father and two brothers. "For me, this procedure is better," she says, "but the
success of the procedure relies on what you will do with your life. Kailangang sundin mo 'yung doctor
mo."
Whether one chooses a bypass or angioplasty, efforts at keeping a healthy lifestyle will keep the heart
going. M

Coated stents revolutionize coronary surgery


ORLANDO
Miniature metal-mesh stents coated with drugs and inserted inside blocked arteries have in just a few
years revolutionized treatment of coronary disease.
While the earliest stents had already sharply cut the number of people undergoing bypass surgery for
coronary blockage, a new generation of drug-treated stents has brought down the incidence of reclogging
to only a small number of patients.
"It's looking very good," Dr. Gerald Fletcher, a Mayo Clinic cardiologist, said of the new technology.
"The benefit is going to be substantial in the long term," he added.
The first extensive studies of three competing stents
presented at last year's annual conference of the
American College of Cardiology (ACC) showed all were
very effective at reducing heart attacks, strokes, and
repeat procedures.
The studies, covering two to three years after
implantation, demonstrated that the new generation of
stents coated with immunosuppressor drugs remained
highly effective.
In the Endeavor stent made by Medtronic Corp., the
incidence of recurring blockage was nearly halved by
the addition of immunosuppressors to the stent. Only
8.1 percent of those using the drug-treated stent
experienced reclogging, according to the report.
The market for drug-treated stents is expected to
reach US$7 billion within two years.
Currently, only two regulator-approved drug-coated
stents are on the market, Cypher by Cordis Corp., a
subsidiary of Johnson and Johnson, and Boston
Scientific Corp.'s Taxus.
Endeavor remains at the testing stage.
In studies comparing 1,386 patients in Europe, Latin America, and Asia over eight months, Cypher and
Taxus came up roughly equal in quality, although they are coated with different drugs.
Citing a separate study, Cypher claimed superiority in treating diabetics, who experience reclogging
more frequently than nondiabetics.
But scientists said both were good for treating coronary blockage.
"There is not one bad and one good, one ugly, and one marvelous to dramatically change practice,"
said French cardiologist Marie-Claude Morice. M AFP

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