Non-surgical treatment

You will not usually be considered for an operation until all other options have been exhausted. This is reasonable, because a heart operation is a large undertaking, with risks involved, and should be avoided if possible. In most cases, you will be receiving some form of drug therapy for your heart complaint, well before surgery is considered. This is often altered or the doses increased according to your symptoms, and is prescribed either by your GP or by your cardiologist at the clinic. There are many drugs available that act to help the heart, and you often need to be on a combination of them, because they work in different ways.
Apart from drugs, there are several other forms of treatment for heart disease that can be considered either before or instead of surgery:
• Angioplasty (PTCA)
• Stenting
• Balloon valvuloplasty
• Pacemaker insertion
• Defibrillator insertion
• Other treatments for abnormal rhythms.

These are often performed, but sometimes work for only a limited period of time and, if the symptoms return, you may well need an operation anyway.
Sometimes, however, the investi­gations reveal that the disease process is severe enough to warrant surgery, and there is no real point in considering other courses of treatment.
The best form of treatment for you is normally decided upon by your cardiologist. When he or she thinks that it is time for surgery to be considered as an option, you will be referred for a consultation with a cardiac surgeon at your nearest cardiothoracic centre. The fact that you are referred for a consultation does not necessarily mean that you definitely need an operation.
However, it means that you will be able to discuss the risks and benefits of surgery with the surgeon, and in most cases an operation will follow.

DRUG THERAPY

This is a very complex subject, with a huge number of drugs on the market today, and it is not necessary to explain how they all work. If you would like to find out more about drug treatments, there are detailed explanations in the Family Doctor publication Understanding Heart Failure.

Ischaemic heart disease (IHD)

If you have angina, it is very likely that you will have some form of nitrate therapy. You may be on a regular dose of ISMN or ISDN, but you will almost certainly have GTN (glyceryl trinitrate) to take during acute attacks. GTN relaxes the muscle in your blood vessels, allowing them to expand or dilate. Your GTN will either come as tablets or a spray, both of which are for use under your tongue, or come as a patch to place on your skin. GTN will relieve your angina attack, but may leave you flushed or with a headache.
Beta blockers are also com­monly used in IHD, because they reduce the blood pressure, slow the heart, and reduce the work that the heart has to do. This means that the energy (and thus oxygen) requirement is less, so they should reduce your symptoms of angina.
Calcium antagonists are the third main group of drugs used in IHD. Among other effects, they allow your coronary arteries to dilate, thus allowing more blood through the narrowings.
These three groups of drugs comprise the maximum drug therapy for IHD. If you are taking all three, you are receiving what is known as ‘triple therapy’, and if you continue to get symptoms you will probably require an operation, or perhaps one of the alternative treatments mentioned below. It is quite common to be on other heart drugs when you have IHD, and now there are a number of new and very effective treatments. You may also be on other drugs that do not specifically work on the IHD, but on associated problems such as heart failure or a coincidental irregular heart rhythm.

Valvular heart disease (VHD)

Most symptoms related to VHD result from heart failure which causes fluid retention. Diuretics (water tablets) are very useful, because they make you pass urine, and this gets rid of unnessary fluid that you have in your body. This is a great help in decreasing both your breathlessness, and the swelling in your legs and ankles.
ACE (angiotensin-converting enzyme) inhibitors help in heart failure, by dilating some of the blood vessels coming into the heart, therefore easing some of the strain of pumping. Digoxin has been very valuable in heart failure for a long time, particularly if you have a fast, irregular heart beat. It slows the heart rate and increases the efficiency of the pump. It is, however, gradually losing favour as a first-line drug for heart failure as new generations of cardiac drugs are being developed.

ANGIOPLASTY AND STENTING

In certain instances, you may have been investigated for IHD, and your angiogram will show either a single narrowing in a single coronary artery, or perhaps single narrowings in only two of the arteries. In such cases, there are clever ways of getting rid of the narrowings without the need for an operation. Precisely which individuals can benefit from these procedures is not always easy to decide, and there is a lot of research looking into this. Having said that, however, they can still be a useful addition to the other forms of treatment available.
Angioplasty, also known as PTCA (percutaneous transcoronary angioplasty), was first performed in 1977, and is a safe and extremely common procedure nowadays. It involves the same preparation as for an angiogram (see page 24), with a catheter being passed into an artery in the arm or groin. Under X-ray control using dye, a wire is passed across the narrowing in the coronary artery. The wire used is different in that it has a deflated ‘sausage-shaped’ balloon on the end. When the part of the wire with the balloon on is lying across the narrowing, it is inflated, which compresses the blockage and leaves the artery open again.
The advantages of this technique are that it can be done without a general anaesthetic, is relatively quick, and does not usually involve a hospital stay of more than one night. The disadvantages are that there is a chance of the blood vessel narrowing again and the angina reappearing. If this happens, you can either have the angioplasty repeated or have an operation. This decision will largely be up to your cardiologist who will have to assess whether this is the right treatment for you. The decision depends on the length and number of narrowings.
Everyone who is about to have angioplasty needs to understand that there is the possibility of completely blocking the coronary artery during the procedure. This shows up as changes on the ECG monitor, and the patient may experience some chest pain. If this happens, an urgent bypass operation is needed. This must be performed immediately, so all patients who undergo angioplasty must sign a consent form for a bypass operation as well, just in case it should be necessary. The chances of this happening are small, however, and are only about 1–2 per cent.

Stenting is very similar to angioplasty, in that it is performed in the angiography laboratory under local anaesthetic and mild sedation only. The difference with stenting is that the balloon is surrounded by a piece of collapsed wire mesh (stent). When the balloon is inflated, the mesh expands to a fixed and open position, which should help prevent the vessel narrowing again in the future (see figure). The balloon catheter is then removed, leaving the stent in place. The chances of this working are slightly better than angioplasty, with less than 20 per cent getting symptoms again within six months.
Stenting is now standard practice in PTCA and it is almost unknown to have a balloon angioplasty per­formed without stent insertion. It combines the active process of opening up the narrowing with a support mechanism to make sure that the artery remains open for as long as possible. There is a wide variety of different stents available, each with its own proposed advant­ages. Stents are the subject of a great deal of research at present, and to date it has been shown that they significantly reduce the chances of the arteries re-narrowing. There are a number of new generations of stents now available, each with their own purported advantages. Some of these can slowly leak out beneficial drugs after implantation (drug-eluting stents), and are expected to be associated with very good results in the future.
It has also been shown that, in some cases, they may offer a similar outcome to a triple bypass, but without all the risks associated with having a major heart operation.

BALLOON VALVULOPLASTY

This is a relatively uncommon procedure, but still has a place in the treatment of stenotic (narrowed) valve disease. It is performed in the angiography laboratory under mild sedation, and involves a balloon catheter being passed across a nar­rowed heart valve and inflated, in much the same way as angioplasty. Over 95 per cent of valvuloplasties in adults are performed for mitral stenosis, but it is also used in some children born with narrow valves.

ELECTROPHYSIOLOGY

Cardiac electrophysiology is a specialised area that deals with rhythm disturbances of the heart. There is a wide variety of investi­gations and treatments available, including a number of very recent advances. The treatments are not surgical but are usually performed in a specifically designated area or even in the angiography laboratory. Common treatments include pace­maker and defibrillator insertion, but more complex procedures are be­coming increasingly used. Rhythm problems can be cured by pro­cedures such as nodal ablation and pulmonary vein isolation, which can be carried out without the need for a general anaesthetic. The Prime Minister, Tony Blair, recently had such a procedure performed successfully for a rhythm disturbance.