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Wed 24 Dec 2008 04:00 AM

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Treating a heart attack

A heart attack results when a heart artery becomes blocked. Most of the heart muscle damage takes place within the first 1 to 2 hours of the heart attack, so therapy to open the heart vessel needs to occur within this time, to save heart muscle and prevent death.

A heart attack results when a heart artery becomes blocked. Most of the heart muscle damage takes place within the first 1 to 2 hours of the heart attack, so therapy to open the heart vessel needs to occur within this time, to save heart muscle and prevent death.There are two main treatments to deal with blocked heart arteries: clot-busting medication (fibrinolytic therapy) and coronary angioplasty/stenting, (also known as primary PCI). These methods have significantly improved the survival and quality of life of heart attack patients.

According to the guidelines of the American College of Cardiology, American Heart Association and European Society of Cardiology, primary PCI is highly recommended in heart attack patients who can undergo the procedure within 12 hours of the onset of symptoms, provided the procedure is performed:

• Quickly, by doctors who perform over 75 interventional procedures per year

• In a facility where over 200 interventional procedures are performed each year

• In a facility with a cardiac surgical capability.

Clot-busting medication

Some patients have a reaction to clot-busting medication. In around 20% of patients, the clots do not disappear. In about 25% of patients there is another blockage of the artery within 3 months, with a recurrent heart attack. These limitations are minimised with the use of primary PCI.

What is angioplasty?

Angioplasty is a method of treating narrowing and blockage of the heart arteries. The cardiologist will temporarily insert and expand a tiny balloon catheter where your arteries have narrowed, to help widen them and improve the blood supply to the heart.

What is stenting?

A stent is a small coil made of a fine, wire mesh that is permanently placed inside the artery to help keep the blood vessel open.

Advantages of primary PCI

In an analysis of 23 studies, the death rate was much lower in those who underwent primary PCI versus clot-busting therapy. Rates of recurrent heart attack and brain stroke were also far less.

Compared to balloon angioplasty, when patients undergo stenting of the heart artery, the rates of renarrowing and the frequencies of recurrent chest pain and repeated angioplasty procedures are lower. Thus, stenting of the coronary artery is usually preferred. With the advent of medicated stents the rates of renarrowing are further reduced. Primary PCI is expensive, but patients on clot-busting medication have higher costs and longer hospital stays.

The risks

Abrupt closure of the heart artery can occur. The incidence has been reduced to 1% with stenting of the artery. Life threatening heart rhythm abnormalities can occur in 4% of patients Emergency cardiac surgery occurs in 4.3% of patients and death in 2.5%. Major bleeding occurs in about 7% of patients Renal failure can occur in up to 2% of patients.

References:American College of Cardiology Guidelines Textbook of Interventional Cardiology, by Topol, 4th edition

Dr Rajesh Raipancholia MBBS, MD, FRCP, FACC (USA), Consultant Interventional Cardiologist.

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