Dr. António Brazão

Cardiothoracic Surgeon

Dr. Diogo Rijo

Cardiothoracic Surgeon

Chronic Coronary Disease

HPA Magazine 13

WHAT IS CORONARY DISEASE?

Coronary disease, or ischemic heart disease, consists in the arteries (coronary arteries), supplying insufficient blood to the heart due to obstruction. There are multiple causes for this occurring, the most common being atherosclerosis. The main risk factors for atherosclerosis are high blood pressure, high cholesterol, diabetes, obesity, lack of physical activity and smoking, which leads to the formation of atherosclerosis plaques that narrow the coronary arteries preventing the normal flow of blood.

WHICH POPULATION IS MOST AFFECTED?
Cardiovascular disease is the leading cause of death in developed countries. Approximately 12% of deaths are due to coronary heart disease. In Portugal, the mortality rate due to ischemic heart disease is 33% per 100,000 inhabitants.
The formation of atherosclerotic plaques on the internal surface of the artery wall is related to a normal aging process, resulting in the progressive decrease of blood flow. This disease increases with age, in severity and precocity and can develop in isolation or synergistically depending on the presence of one or more risk factors mentioned above. 
Hereditary factors can also play a role in the develop-
ment of this pathology. However, there are cases where risk factors are not perceived. Males are more frequently affected and in women some hormonal protection is evidenced. 

WHAT ARE THE SYMPTOMS OF CORONARYDISEASE? 
The typical symptom of ischemic heart disease is angina pectoris (or simply angina), which is a feeling of discomfort or tightness of the chest, usually on the left side, irradiating to the neck or left arm, although it can radiate to other parts of the chest and even to the abdomen. Angina occurs when the heart muscle (myocardium) needs more blood than what it is receiving, causing the myocardium to become ischemic. The consequent lack of blood flow and oxygen to the cells causes chest pain. 
Angina occurs when the heart muscle (myocardium) is receiving less blood than what it needs, causing the myocardium to become ischemic and the consequent lack of oxygen in the cells causes chest pain. 
Angina can occur when the patient is in exertion, becoming progressively worse but improving with rest, this is known as stable angina. Angina can also occur unrelated to effort and is known as unstable angina.
If the ischemia persists for a long period of time, it can lead to acute myocardial infarction, resulting in death of the cardiac muscle, which, depending on magnitude or arrhythmias, can lead to sudden death.
Symptoms that are not characteristic of ischemic heart disease can exist, even in the  absence of angina, namely pain in the stomach, shortness of breath or tiredness, with no other symptoms of the disease, the so-called “silent ischemia” (particularly in diabetic patients).

HOW IS CHRONIC CORONARY DISEASE DIAGNOSED?
In most cases, coronary heart disease can be diagnosed by a clinical evaluation and the patient’s medical history, especially when there are typical symptoms. Depending on their severity, some tests may be requested to complement the diagnosis, establish a treatment strategy and to define a prognosis. The necessary exams are progressively requested in various stages, as the disease needs to be confirmed and studied. Some of the diagnostic tests requested are:
· Heart Stress Test: consists of walking /running on a treadmill under cardiac monitoring, to assess whether there are signs of ischemia with effort, in the form of angina and/or electrocardiogram alterations. If this test is positive, there is usually a need for further tests.
· Stress Echocardiogram/Pharmacological Overload: the echocardiogram will assess heart alteration when subjected to stress situations. If there is heart disease  the heart is unable to work properly and its beating is less vigorous in the affected areas.
· Cardiac Perfusion Scintigraphy and Overload Magnetic Resonance Imaging (MRI): are more expensive and complex exams, which will assess the areas of the myocardium that are receiving less blood due to coronary disease. These exams are carried out only when there is doubt as to the results of the previous exams or as a complementary study to assess the necessity for invasive treatment. 
· Angio-CT Scan: consists in a computed tomography scan where heart arteries and their “tightness” can be observed.
· Coronary Catheterization: is an invasive exam, and also the one of choice, to confirm the diagnosis. It is indicated for patients with high suspicion of coronary disease. It consists of introducing a catheter through an artery of the arm (or leg) until it reaches the heart. A contrast liquid is injected into the artery to evaluate its pathway and degree of obstruction, if any. 

TREATMENT OPTIONS
Treatment options are as follows: medical/clinical, percutaneous and surgical.
Medical treatment is indicated for the mildest forms of coronary heart disease, with prescription drugs in order to stabilize the disease, control symptoms and improve the prognosis.
Percutaneous treatment consists in coronary catheterization, where stents (tube-shape device) are implanted in the artery to prevent an occlusions, maintaining the artery open, restoring blood flow and reducing ischemia. This technique has precise indications and very good results, a symptomatic improvement is immediately noticed by the patient and it has an important prognostic impact. It is necessary to remain in hospital for a few days and the patient can resume his normal activity within a few weeks.
Surgical treatment consists of surgery of the arteries 
of the heart, known as coronary bypass surgery. Chest arteries (internal mammary arteries) are used which are connected to the arteries of the heart, in front of the occlusions, thus restoring blood flow and decreasing ischemia. This is the most invasive option as it is necessary to open the chest cavity to reach the heart. It is known as “open heart surgery”. There are currently other strategies using smaller openings of the chest that result in smaller scars (key-hole surgery). The patient usually remains in hospital for 5 days, and can resume his normal activity within a few weeks. Despite being the most invasive method, it is a very low risk procedure and according to medical studies, this method has a number of indications, allowing for better long-term results, less need for drugs in the future, resulting in a clear improvement of the patient's overall prognosis. It is undoubtedly the treatment method to be considered in severe chronic coronary heart disease.
At the HPA Health Group, the Interventional Cardio-
logy and the Cardiothoracic Surgery Teams work together as the “Heart Team", from such a time as the initial diagnosis is reached until the most appropriate treatment is proposed in each particular case, for each patient.