1. Does an ECG indicating “myocardial ischemia” mean that I have coronary heart 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-angina medication 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 resting for a few minutes to more than ten minutes.
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, there is no need to be overly worried just because the word “myocardial ischemia” appears on the ECG report, and do not take medication rashly.
2. Can coronary CT confirm the diagnosis of coronary artery 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 traditional 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 result is negative, that is, no obvious coronary artery lesion is found, the possibility of coronary artery disease can be basically ruled out; but if the coronary artery is found to be narrowed or blocked, coronary angiography is often still needed to confirm the exact location and extent of the lesion. If the coronary artery is found to be narrowed or blocked, coronary angiography is often still required to confirm the exact location and extent of the lesion and to guide the next step of 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 angiogram, but I am afraid of the risk, should I undergo the angiogram?
As mentioned above, 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 results of the angiography 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 operation and inevitably brings risks (even fatal risks), the technology of coronary angiography is very mature and the overall risk is very small; more importantly, the risk of coronary angiography is so small compared to the undiagnosed coronary artery disease that the most appropriate treatment plan cannot be chosen, that it is worth the risk.
4. What are the treatments for coronary artery 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), which means that these treatments themselves can cause trauma to the patient’s body. So, how to choose among these three methods? There is actually a subtext embedded 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 trend 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, in a patient with left main stem and three branches lesions, the effect of drug treatment alone may not be effective in reducing the patient’s risk of sudden death or myocardial infarction, while coronary artery bypass surgery can completely relieve the threat of lesions. From a macroscopic point of view, surgery, the most traumatic method, is instead the least risky overall, which is the basic principle of physician selection.
5. How to determine if a patient needs coronary artery bypass surgery?
Whether a patient needs to undergo coronary artery bypass surgery or not depends on the location and degree of coronary artery disease, as well as the function of the heart 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 combination of data.
6.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 they 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 the surgery or wait for the onset of the infarction before operating is like gambling with 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 it because we are afraid of the explosion is undoubtedly unwise.
7. 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 still 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.
8. The doctor suggested the elderly to undergo coronary artery bypass surgery, I am worried that he/she is too old to handle 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.
9. My doctor said that my coronary artery lesion is very serious and cannot be put into stents, and suggested me to do 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 want 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 because it must be done with the help of imaging, it cannot really be done under direct vision and is relatively less controllable; moreover, if the coronary lesions are too diffuse, many stents may have to be placed 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 coronary artery lesions. 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 their doctor’s advice and seek treatment that is appropriate for their condition.