Since logging on in 2010, I have found this to be a great platform for doctor-patient communication. Among the many questions I have been asked, the main ones revolve around the diagnosis and treatment of coronary artery disease. Many of these questions are very similar. Therefore, I have commissioned my assistant to make a rough summary of these questions in the hope that it will facilitate your inquiries. It should be noted that I do not intend to copy the contents of medical textbooks, but I hope that patients will understand the doctor’s thinking in the process of diagnosis and treatment and the basic views on certain core issues, so I may be a bit “reticent” in writing. I hope you will criticize and correct me. In addition, since my specialty is cardiovascular surgery, I would like to ask the reader to bear with me for choosing questions that are less related to cardiology treatment. I. Diagnosis of coronary artery disease 1.Electrocardiogram indicates “myocardial ischemia”, does it mean that I have coronary artery disease? ECG is undoubtedly an important tool for diagnosing coronary heart disease, but many primary hospitals diagnose atypical ECG changes as “myocardial ischemia” and even give anti-anginal drugs without differentiation, which is obviously inappropriate. Although the clinical manifestations of coronary heart disease are diverse, most patients have typical clinical symptoms, such as chest tightness and chest pain after exertion or excitement, which can be relieved after a few minutes to more than 10 minutes of rest. Similarly, only “typical” ischemic ECG manifestations have diagnostic significance; moreover, the diagnosis of coronary artery disease is often made by cross-referencing with the basic conditions of the patient (e.g., age, other existing diseases, etc.), clinical symptoms, and the detection of myocardial damage markers. Therefore, it is not necessary to worry too much just because the word “myocardial ischemia” appears on the ECG report, and do not take medication hastily. 2.Can coronary CT confirm the diagnosis of coronary heart disease? Who can’t do CT examination? Coronary CTA (Computed Tomographic Angiography) is an emerging diagnostic tool in recent years. It is favored by clinicians because it is less invasive and less dangerous than conventional coronary angiography. It should be emphasized, however, that although CTA has a high sensitivity and specificity (i.e., accuracy), it is not yet a substitute for coronary angiography, which remains the “gold standard” for the diagnosis of coronary artery disease. If the test is negative, i.e., no obvious coronary artery lesions are found, coronary artery disease can basically be ruled out; however, if stenosis or blockage is found in the coronary arteries, coronary angiography is often still required to confirm the exact location and extent of the lesions. If the coronary artery is found to be narrowed or blocked, coronary angiography is often required to confirm the exact location and extent of the lesion and to guide the next treatment. Therefore, when a patient has been diagnosed with coronary artery disease, there is no need to do coronary CTA, but to undergo coronary angiography directly. In addition, there are some technical limitations of CTA examination, for example, if the heart rate of the subject is too fast (more than 75 beats/min at quiet) or arrhythmia, the accuracy of CTA will be affected; if the heart rate cannot be effectively controlled, CTA examination is not suitable. Some core cities have dual-source CT equipment, which can solve the above problems. If you must do CTA, you can find a hospital with dual-source CT for consultation. Other issues such as contrast allergy, heart failure and other patients who are not suitable for CT will not be discussed here. 3. My doctor suggested me to have a coronary angiography, but I am afraid of the risk, should I undergo the angiography? As mentioned before, coronary angiography is the “gold standard” for the diagnosis of coronary artery disease. Its importance lies not only in the fact that it is the most reliable means to confirm the diagnosis of coronary artery disease, but also in the fact that the angiographic results are the basic basis for deciding what treatment the patient should receive. Whether it is interventional treatment (i.e. stenting), coronary artery bypass surgery, or even drug treatment, the basic plan is based on the imaging results. Therefore, we recommend coronary angiography for all patients with confirmed coronary artery disease in areas where it is available. Although coronary angiography is an invasive procedure that inevitably poses risks (even fatal risks), the technology of coronary angiography is very mature and the overall risks are very small; more importantly, the risks of coronary angiography are so small that it is worthwhile to take such risks compared with the risk of not being able to choose the most appropriate treatment plan for undiagnosed coronary heart disease. II Coronary heart disease treatment 1. What are the treatment methods for coronary heart disease and how to choose them? There are only three modern treatments for coronary artery disease: drugs, interventions (also known as stents) and bypass surgery. Among them, the latter two are invasive operations (or invasive operations), that is to say, these treatments themselves will cause trauma to the patient’s body. So, how do you choose between these three methods? There is actually a subtext here. Why should we choose an invasive, high-risk treatment over a non-invasive, low-risk drug treatment? The answer is actually quite simple: cardiovascular disease is currently the disease with the highest morbidity and mortality rate in China, and in the world. Its danger is so great that it cannot be lifted by conventional drug therapy, which forces us to seek more effective and also more drastic treatments. Many people are aware of the horror of malignant tumors and know that surgical removal may be the only way to survive, and are happy to accept this view. But when it comes to coronary artery disease, an affliction with a much higher incidence and overall risk, instead, we are stuck with a misconception that we must break. In fact, choosing different treatment options is a process of weighing the risks and benefits of each therapy and finding a balance among them. The three therapies mentioned above have an increasing tendency of damage to the organism, and the corresponding rescue targets are not the same. In general, the more complex, severe, and diffuse the coronary lesion, the more powerful the treatment is needed, and the so-called greater the risk, the greater the benefit. For example, for a patient with a left main stem and three branches lesion, the effect of drug treatment alone may be difficult to effectively reduce the patient’s risk of sudden death or myocardial infarction, while coronary artery bypass surgery can completely relieve the threat of the lesion. From a macroscopic point of view, surgery, the most traumatic method, is instead the least risky overall, and this is the basic principle of the doctor’s choice. 2. How to determine if a patient needs to undergo coronary artery bypass surgery? Whether a patient needs to undergo coronary artery bypass surgery and whether the surgery is possible depends on the location and degree of coronary artery lesions, as well as the heart function and the overall condition of the body. The basic basis for determining coronary artery disease is coronary angiography. As mentioned above, coronary angiography has a decisive value in determining coronary artery lesions, thus becoming the “gold standard” for the diagnosis of coronary artery disease. If the angiogram confirms extensive, severe stenosis or blockage of the coronary arteries, bypass surgery is likely to be required. Of course, the final decision of whether a patient can undergo bypass surgery will depend on a variety of data. 3.My doctor suggested me to have coronary artery bypass surgery, can I wait until my symptoms are heavier or after my myocardial infarction? The symptoms of patients with coronary artery disease do not exactly correspond to the severity of coronary artery lesions. Some patients usually have almost no obvious symptoms, but the coronary lesions are already very serious. For such people, surgery is necessary even if there are no clinical manifestations. In addition, the morbidity of coronary artery disease is characterized by its suddenness. As we all know, myocardial infarction is a serious consequence of coronary heart disease, with a high death rate and a great impact on the patient’s cardiac function. Doctors can only roughly determine how likely a patient is to have a myocardial infarction, but cannot anticipate when it will occur. Therefore, we recommend that patients with coronary artery lesions of a certain severity undergo early intervention (also known as stenting) or bypass surgery, which is to restore the coronary blood supply early and relieve the threat of myocardial infarction. Expecting to delay surgery or wait for the onset of an infarction before operating is like gambling with your life. To use an analogy, a diagnosis of coronary heart disease is like carrying a bomb, we do not know when it will explode, but refusing to defuse the bomb because of fear of explosion is undoubtedly unwise. 4.I have already had a myocardial infarction and now my heart function is very poor, can I still have bypass surgery? As the name implies, myocardial infarction refers to necrosis of the heart muscle due to ischemia. After the first myocardial infarction, there is a high possibility that the patient will have another heart attack within a short period of time. Therefore, as long as the patient’s physical condition still allows, bypass surgery should be done as soon as possible to restore the blood supply to the heart. Even if the patient has shown signs of heart failure, in order to save the still surviving myocardium, surgery should be strived for after medication to make the heart function stable. In general, due to the severe effects of myocardial infarction, the patient’s heart function and physique will be greatly impacted. The ability to tolerate surgery is definitely reduced and the risk of surgery is elevated. However, because of this, it is all the more important to preserve the still surviving myocardium from the threat of ischemia. Therefore, the more patients who have had a heart attack, the more often they need a bypass, not the other way around. 5. My doctor recommended that the elderly person undergo coronary artery bypass surgery, and I am worried that he/she is too old to undergo the surgery. I have never been shy about the fact that coronary artery bypass surgery is a relatively damaging treatment. It must be acknowledged that advanced age is one of the important risk factors for the surgery. However, as mentioned earlier, the key is whether the benefits of the procedure clearly outweigh the risks. In fact, the average age of coronary artery disease is about 60+ years, so the vast majority of patients requiring bypass surgery treatment are between 60 and 80 years of age, and most patients of advanced age can still tolerate bypass surgery well. At the hospital I currently work at, the oldest patient was 88 years old, and the results of the surgery were excellent. Therefore, age is not the only factor we should consider, but of course, the older the patient, the more careful the preoperative evaluation will be. 6. My doctor said that my coronary artery lesion is very serious and cannot be put in stents, and suggested me to have coronary artery bypass surgery, can I try stenting? As mentioned earlier, not all coronary lesions are suitable for interventional treatment (i.e., stenting), just as bypass surgery is not a panacea. In general, intervention is more appropriate for relatively limited lesions, while bypass surgery is more effective for complex, diffuse lesions. Some patients may wish to try intervention anyway out of fear of surgery, but this is a misinterpretation of the concept of risk. Comparing the two treatments, each has its strengths and weaknesses. Bypass surgery requires general anesthesia and chest opening, which is definitely more traumatic and its risks stem from the high degree of injury. Interventional treatment is of course much less damaging to the body, but it cannot really be performed under direct vision because of the need for imaging, which is relatively less controllable; moreover, if the coronary lesions are too diffuse, many stents may have to be inserted to resolve all the lesions. More stents mean a higher possibility of complications. Therefore, we must look at the technical characteristics of both and choose the “most appropriate” treatment according to the status of the coronary artery lesion. In fact, many interventionalists have a very clear understanding of the technical characteristics of both, and many patients come to me on the recommendation of their cardiologist. Patients should trust the advice of their doctors and seek treatment that is consistent with their condition. 7.How much does it cost to have coronary artery bypass surgery? Can I be reimbursed? The basic cost of bypass surgery at the office I work for is about 60,000 RMB, and this amount is common everywhere. We also offer less invasive techniques such as endoscopic access to the bypass and the use of a disposable proximal bypass anastomosis device, which can raise the cost of treatment by about $20,000. Bypass surgery should be reimbursable, usually about half, I believe.