Recently a gentleman from India contacted me and asked me for some advice.
He told me that he was 75 years old and had been experiencing chest discomfort and therefore had to go to his local hospital in India where he was investigated and told that he had heart artery narrowings in all of blood vessels and he needed an urgent cardiac bypass operation. However since he had been started on some tablets, his pains had all gone and he was now back to being completely asymptomatic. So he was faced with a dilemma because he felt well but was being advised an urgent operation which was going to be both very expensive for him to fund but also a very invasive procedure (which understandably scared him).
So I asked him whether he had spoken to his doctor about his concerns. He told me that he had but at the mere prospect of being questioned, his doctor had become quite angry and told him that without the operation there was a very high likelihood that he would either have a massive heart attack or be dead within the next 3-6 months. This scared the patient even more and now he was really completely overwhelmed and lost as to what to do. Should he have the operation to live longer?
In this video I wanted to talk about how dangerous stable angina is and whether a heart bypass done for this condition does indeed prolong life.
Now before I start I would always urge that patients make important decisions like this in concert with their doctors and individual situations may be different and therefore anything i say in the video should never replace an honest and detailed discussion with your own doctor.
Firstly I will talk about angina and then i will talk about the treatments and finally about this very interesting study which was called the ISCHEMIA trial.
1. What is angina and what is stable angina
The heart is a muscle and therefore needs a blood supply and when the heart is called onto do more work such as during exercise, more blood is needed to match the increased demand. If for any reason, the demand does not match the supply, the heart muscles will not get the blood they need and start suffocating. As these heart muscles suffocate, the patient will manifest with chest discomfort and/or breathlessness and will be unable to keep going with whatever is causing the increased demand. The symptoms of chest discomfort which result from this demand supply mismatch is called Angina. Usually the supply doesn’t match the demand because of progressive narrowings within the vessels that develop due to increasing age, wear and tear and comorbidities such as diabetes and high blood pressure and therefore in most people who have angina, when you examine the vessels by a test called angiography, you will usually expect to find significant narrowings within the blood vessels.
Now any condition can only do two things to us - it can impact on our quality of life or impact on our length of life or both and therefore when we plan management, management has to be geared towards improving quality of life by removing symptoms and we also want to give patients those treatments that would prolong life.
Assessing the benefit of an intervention designed to improve quality of life is easy. You administer the intervention and the patient will tell you if their quality of life has improved as a consequence.
Assessment of the benefit of an intervention designed to improve length of life in an individual Is very difficult because there is no real way to be certain that you have prolonged life and therefore the only way to know whether what you are doing is worth doing is to rely on data from studies done in populations of patients that are similar to the individual that is sat in from the of you.
In angina, both quality of life and length of life can be affected and in terms of quality of life, we know that there are 3 main options depending on the severity and complexity of the narrowing causing the angina.
The 3 options are
Pills eg Aspirin, beta blockers, nitrates and statins
Stents
Bypass operations
Whilst pills are an inconvenience, stents and particularly heart bypasses are pretty big and scary interventions.