Coronary Artery Disease, Part 3: PCI vs CABG vs Medical Therapy

For “stable obstructive coronary disease,” there are generally three options for angina treatment: percutaneous coronary intervention, coronary artery bypass graft surgery, or medication therapy. This episode explains what these terms mean and gives a general overview of these options for treatment. Questions and comments are encouraged!

Hello my friends thank you for joining me today for those of you new to the channel my name is dr. todd fergus and i am an interventional cardiologist based in green bay wisconsin today is part three in a four-part series on cornering artery disease the first and second episodes were posted earlier and i’d encourage you to browse for those for today we will be

Talking about the variety of treatments for obstructive coronary disease so let’s get started first of all let’s just review the difference between obstructive and non obstructive coronary disease so non obstructive coronary disease what i like to call lumps and bumps is basically just mild athos kradic changes or mild plaque in the arteries there may be a 20%

Narrowing there might be a 40% narrowing but nothing that’s obstructing blood flow so while this may not cause any symptoms it may not actually limit the blood flow in the heart it is a marker of elevated risk so non obstructive coronary disease needs to be treated aggressively and that treatment usually consists of a combination of lifestyle modifications like diet

Exercise and smoking cessation as well as some medications so medications like a baby aspirin daily and a statin medication the medications that we know will reduce the risk of future cardiovascular events like stroke heart attack or death now on the contrary we have obstructive coronary disease so this is plaque buildup that’s narrowing the artery by 70 or 80 or

90 percent or actually obstructing blood flow to the heart and this also just like non obstructive coronary disease as a marker for elevated cardiovascular risk but in addition to that obstructive cornices can also cause symptoms of angina and we’ve talked about this during prior episodes that angina might be chest pain chest tightness chest burning particularly

When exerting oneself or other less specific symptoms such as shortness of breath or fatigue obstructive coronary these also needs to be treated aggressively with lifestyle and medications to prevent those cardiovascular events like stroke heart attack or death but the anginal symptoms that come with obstructive coronary disease may need to be treated with other

Modalities as well now what we’re not talking about today is acute coronary syndromes that would be unstable angina or heart attacks these are a completely different discussion and will be discussed elsewhere for today we’re talking about stable obstructive coronary disease so let’s talk about the options for therapy for angina so there’s three main options and the

First one is medical therapy so medical therapy means using medications to treat the symptoms without actually fixing fixing the blockages the second option is pci or percutaneous coronary intervention and that generally means a combination of angioplasty and/or stents and then the third option is cabbage or coronary artery bypass grafting that’s what’s traditionally

Called open heart surgery or bypass surgery so let’s start with medical therapy first now a lot of people raise an eyebrow when we say medical therapy because they’re thinking well you’re a doctor you practice medicine isn’t everything you do medical therapy well yes in a way but when we talk about medical therapy we’re specifically talking about using medications

Or pills to treat the symptoms there’s primarily for different categories of anti anginal drugs the first one in no particular order is beta blockers so beta blockers are medications like metoprolol atenolol carvedilol and there’s several more and the second category is calcium channel blockers and these are medications like diltiazem or verapamil or amlodipine

Then there’s a medication in its own category called ranolazine that’s a relatively newer medication and tends to be more expensive and yet is very effective then the fourth medication that many people have heard of is nitroglycerine now nitrates come in a variety of different forms it can be the classic sublingual tablet that you’ve heard of people putting under

Their tongue but nitrates also come in a long-acting form that can be taken as a once-a-day pill or even a patch that can be worn on the skin all four of these categories of medications work in different ways and may be more or less effective in any given patient oftentimes we use a combination of two or three or even all four of these categories to man manage a

Patient’s angina a second way to treat angina is by fixing the blockages with pci which stands for percutaneous coronary intervention and this generally involves a combination of balloons and stents to open up the blockage now balloons and stents are inserted through a catheter that’s placed through an artery usually either through the groin or through the wrist

And threaded up to the heart first we would place the stent within the lesion second we would inflate the balloon to deploy the stent and expand the lesion and then third we would deflate the balloon leaving the stent behind and then the artery is open allowing blood to flow freely now we generally do this with one of two types of stents there’s the original what

We call bare metal stents they’re the non drug coated stents which work very well but do have a chance of renewing about 15 to 20 percent at a time or the second option which we’ve had now for over 15 years is drug eluting stents or drug coated stents and that drug coating will prevent any scar tissue from forming on the stent with drug coated stents the chance

Of instant restenosis is less than 5% this is what it looks like in a real angiogram on a real patient so you can see the arrow is pointing to the narrowing on the left sided picture and then once that stent goes in that artery is fully opened so blood can flow through and then the third option for treatment of angina is cabbage or coronary artery bypass grafting

Surgery so with this surgery we’re typically using an arterial conduit so either the left intern mammary artery which is called the lima or the right internal mammary artery which is the rema or even one of the radial arteries out of the wrists and use these as a conduit or a bypass to reroute the blood flow around the blockage or we can use a vein graft typically

A saphenous vein graft that comes out of the leg and plug one end of that vein into the aorta plug the other end into the coronary artery downstream from the blockage which effectively reroutes blood flow around that blockage and allows that blood to get into the heart muscle downstream so those are the three options for treatment of angina medical therapy pci

Or cabbage how do we choose which one to use well as you can imagine it can get pretty complicated but here are a few basic guidelines anti anjan ulm ed occations are oftentimes used in people with blockages and very small vessels so vessels that are too small for our smallest stents or smallest dentists only two moments in diameter or sometimes patients have had

Every blockage in their artery that could be fixed has been fixed they’re still having angina and then we’re just stuck using medications for coronary intervention this is very effective in people with single or double vessel disease so blockages and one or two of their coronary arteries particularly when it’s what we call anatomically favorable so a pretty straight

Vessel soft plaque and in these patients where the anatomy is favorable we often times get a very durable result with coronary intervention and a lot of patients ask me how long will these stents last well in most situations when the immediate result of the procedure is good we can expect that stent to stay open forever over 95% of the time and then as far as bypass

Surgery is concerned we are oftentimes using bypass surgery when the anatomy is not favorable for angioplasty or stents and this is particularly true in patients who have diffused multi vessel disease and diffuse means plaque or buildup or severe blockage along the entire path of the artery as opposed to one discrete blockage that could easily be fixed with a stent

When someone has more diffuse disease the only way to stent that would be to use what’s called a full metal jacket or filling the entire artery with stents and generally that’s not favorable long term sometimes it’s very straightforward to determine the best way to treat someone’s blockages whether it’s with medical therapy versus pci versus cabbage but sometimes

It is a very complicated decision and requires an extensive discussion between the patient and his or her doctor well thanks for listening to this discussion today i hope you enjoyed it and if you did please hit the like button stay tuned for future episodes including part 4 in this series on coronary artery disease and in the meantime stay active eat healthy and be well you

Transcribed from video
Coronary Artery Disease, Part 3: PCI vs CABG vs Medical Therapy By Todd Fergus