CORONARY ARTERY PROCEDURES Cardiac Catheterization, Stenting, and Bypass Surgery
Coronary Artery Disease Your doctor has told you that you may have coronary artery disease (CAD). Having CAD means that the vessels carrying blood to your heart muscle are narrowed or blocked. Left untreated, CAD can lead to a heart attack or sudden death. The good news is that there are procedures to diagnose and treat this type of heart problem. This booklet can help you learn about coronary artery procedures. This way, you and your doctor can make a treatment plan that s right for you. Signs of CAD Your doctor may suspect you have CAD because: You have angina. This is often described as a painful, heavy, or tight feeling in or near the chest, but it varies from person to person. Angina is a common symptom of CAD. You had tests that suggest heart disease is likely. These include imaging tests or an electrocardiogram (ECG or EKG). You have heart disease risk factors. These are health and lifestyle issues that increase a person s chance of developing CAD. Risk factors for CAD include family history of heart disease, unhealthy cholesterol levels, high blood pressure, and diabetes. Smoking, being overweight, and lack of physical activity also increase risk. 2
CONTENTS The Benefits of Coronary Artery Procedures Coronary artery procedures can be used to diagnose and treat blockages in the heart s arteries. Treatment can reduce symptoms of angina. It can also make a heart attack less likely. Coronary artery procedures include: Cardiac catheterization to diagnose CAD. Angioplasty and stenting to treat blockages. Bypass surgery to treat blockages (if other procedures won t help). 4 How CAD Develops 6 Before Coronary Artery Procedures 8 Diagnosing CAD: Cardiac Catheterization 10 Treating CAD: Angioplasty and Stenting 11 After Your Procedure 12 Treating CAD: Coronary Artery Bypass Surgery 14 Recovering from Your Procedure 3
How CAD Develops The heart is a muscular organ. It pumps blood throughout the body. Like other muscles, the heart needs a steady supply of oxygen to function. Blood carries oxygen to the heart and the rest of the body through vessels called arteries. In the heart, the coronary arteries supply blood and oxygen to the muscle. If the heart doesn t get enough oxygen, angina or a heart attack can result. Healthy Coronary Arteries Coronary arteries are blood vessels that wrap around the surface of the heart. Their job is to supply the heart muscle with oxygen-rich blood. The amount of oxygen the heart needs depends on how hard it s working. For example, exercise makes the heart beat faster. This increases the heart s need for oxygen. Healthy arteries can meet this need. They have smooth, flexible walls that can support changes in blood flow. The right coronary artery supplies blood to the right side and bottom of the heart. Aorta Smooth inner lining The left main coronary artery divides into two branches, described below. The circumflex coronary artery supplies blood to the back, left side, and bottom of the heart. The left anterior descending coronary artery supplies blood to the front and left side of the heart. 4
When You Have CAD Coronary artery disease starts when the lining of a coronary artery is damaged. Having one or more risk factors, such as smoking or unhealthy cholesterol levels, can speed up and worsen this damage. Over time, plaque builds up within the artery wall. Plaque is a fatty material made of cholesterol and other particles. The buildup is called atherosclerosis. It narrows the space inside the artery. It also makes artery walls less able to expand. At times when the heart needs more oxygen, not enough blood can get through to meet the need. This can lead to angina. Plaque Plaque forms between layers of the artery wall when the inner lining of the artery is damaged. Damage Narrowed space Plaque narrows the channel where blood flows. The artery can t meet increased demands for blood. Heart Attack Blocked artery Plaque may rupture, narrowing the artery even more. A blood clot may cut off blood flow. A heart attack (myocardial infarction) occurs when a coronary artery is blocked by plaque or a blood clot. When this happens, the heart muscle beyond the blockage doesn t get oxygen. That part of the heart muscle dies. This damage can t be reversed. Though many people survive them, heart attacks can be deadly. 5
Before Coronary Artery Procedures You and your doctor will talk about your options. Then you ll decide on a plan that is best for you. Be sure to ask any questions you have. Your healthcare team will tell you how to prepare for your procedure. Follow the instructions you re given. Be Informed Depending on the extent of your problem, your doctor may recommend medication or lifestyle changes. These may help ease your symptoms. But you may need a procedure to gather more information about your heart. Or it may be time to try more extensive treatment. You and your doctor will discuss your options. Understand what a coronary artery procedure can and can t do for you. Any heart procedure has risks. Be clear what the risks are for you. Also learn what you need to do to prepare for your procedure and recover from it. By being informed, you can help your doctor ensure that your needs are met. 6
Preparing for Your Procedure Tell your doctor about all the medications you take. This includes those bought over the counter and any herbal remedies or supplements. This also includes medications to prevent blood clots. You may be asked to stop taking some or all of them. In some cases, your doctor may prescribe a new medication to take before your procedure. Tell your doctor if you are allergic to iodine or any medications. Also mention if you are pregnant or think you could be pregnant. Ask your doctor how long before the procedure to stop eating and drinking. This is often after midnight the night before. If you ll be staying in the hospital overnight, pack a bag in advance. Risks and Complications The risks and possible complications of coronary artery procedures include: Bleeding from the catheter insertion site (cath procedures) Allergic reaction to the contrast fluid (cath procedures) Damage to blood vessels or heart tissues (cath procedures) Kidney failure (cath procedures) Emergency bypass surgery (cath procedures) Breathing or other lung problems (surgery) Excessive bleeding or wound infection (surgery) Blood clots Infection Abnormal heartbeat called arrhythmia Heart attack, stroke, or death 7
Diagnosing CAD: Cardiac Catheterization Cardiac catheterization is a procedure that is done using a catheter. This is a long, thin, flexible tube. The catheter is inserted into a blood vessel through a small incision or puncture. It is guided into the heart, where it s used to take pictures and do tests. This procedure takes an hour or longer. At the Hospital Once you arrive at the hospital, you ll prepare for the procedure. Here s what to expect: You will likely be asked more than once what your name is and what procedure you are having. This is for your safety. You ll be asked to empty your bladder and bowels. Hair may be removed from the skin where the catheter will be inserted. For safety, you will be given You ll then be taken to the cath lab. a wristband for identification. In the Cath Lab Once in the cath lab, you ll lie on a table beneath x-ray cameras. Video monitors will be nearby. You ll be given medication through an IV line to relax you. You ll be drowsy but awake during the procedure. A local anesthetic numbs skin and surrounding tissue. Then an introducing sheath is inserted into an artery in the groin, arm, or wrist. The sheath remains in place through the whole procedure. In some cases, pressures within the heart chambers are measured. This requires a second sheath in the same area. A catheter and guide wire are put into the sheath. They are threaded through the arteries to the heart. This takes just seconds. Blood vessels have no pain nerves, so you won t feel their passing. Once the catheter is in place, the guide wire is removed. During cardiac catheterization, guide wires and catheters may be removed and replaced several times. This is done to reach each of the coronary arteries. 8
Arm insertion site Wrist insertion site Groin insertion site Catheter Heart Evaluating Coronary Arteries Contrast fluid is injected through the catheter into the artery. This allows the blood flow channel to show up on x-rays. You may feel a warm flush as the contrast fluid enters your system. Several pictures (angiograms) are then taken. The pictures show the amount of narrowing in the artery and its exact location. This helps your doctor decide whether to open or bypass blockages. Your doctor may do a procedure (angioplasty and stenting) right away to open the blocked arteries. Or this may be done at a later date. If bypass surgery is a better option, your doctor will talk with you about this after the catheterization. Narrowed artery This angiogram confirms CAD. Narrowing in the artery is shown above. 9
Treating CAD: Angioplasty and Stenting If an angiogram confirms a blockage, angioplasty and stenting may be the best treatment option. This procedure widens the channel (lumen) where blood flows in an artery. A mesh tube called a stent may be used to keep the artery open. The stent may be coated with a drug to help reduce scar tissue inside the artery. This is called a drug-eluting stent. Balloon Angioplasty Catheter Plaque A balloon-tipped catheter is inserted into the narrowed area in the artery. Stenting Catheter Plaque Balloon Balloon Stent Compressed plaque Once in place, the balloon is inflated. This flattens the plaque against the artery walls. Compressed plaque Widened lumen The lumen is widened. This improves blood flow. Stent A flexible mesh tube (stent) is guided into the artery. The balloon is inflated to open the stent and flatten plaque. The stent remains to hold the artery open. 10
After Your Procedure No matter which catheter-based procedure you have, the information below will help you understand what happens afterward. Be sure to follow all instructions from your doctor and healthcare team closely. Closing the Insertion Site The sheath in your groin, wrist, or arm will be removed. The insertion site will be closed with manual pressure or a closure device. This may be done in either the cath lab or your hospital room. You may need to keep still, with your leg or arm straight, for 2 to 6 hours. How long may depend on the insertion site and the type of closure used. You ll be closely watched until you re ready to go home. Many people stay in the hospital overnight. Going Home Have an adult family member or friend prepared to drive you home. You can go home when: Your condition appears stable. The insertion site is not bleeding. Your blood tests are cleared by your doctor. You have no signs of infection. You can urinate. When to Call the Doctor After a catheter-based procedure, call your doctor if you have: Increasing pain, swelling, redness, warmth, bleeding, or drainage at the insertion site Fever of 100.4 F (38 C) or higher Angina or shortness of breath Inability to urinate or blood in the urine Severe pain, coldness, or a bluish color in the leg or arm where the catheter was inserted 11
Treating CAD: Coronary Artery Bypass Surgery Sometimes, angioplasty and stenting can t do enough to improve blood flow. If so, coronary artery bypass surgery is often advised. This procedure reroutes blood flow to the heart. To do this, a new pathway is created around the blocked portion of an artery. A blood vessel from the chest or another part of the body is often used to bypass the blockage. Surgery to Bypass Blockages Bypass surgery is done in an operating room. In most cases, it takes between 3 and 6 hours. A blood vessel from the leg, arm, or chest will be used to make each bypass graft. Removing these vessels usually doesn t harm blood flow in the rest of the body. To reach the heart, the surgeon will likely make an incision down the center of your chest. The breastbone is separated. Then: Aorta If a vessel from the arm or leg is used for the bypass graft, one end will be sewn to the aorta. The other end will be sewn to the coronary artery below the blocked portion. If a vessel from the chest wall is used for the bypass graft, one end is already attached Bypass graft to a branch of the aorta. The other end will be cut and attached to the coronary artery below the blocked portion. Bypass graft Bypass graft Coronary artery If you have more than one blockage, more than one bypass may be needed. 12
After Bypass Surgery Right after surgery, you ll be taken to the intensive care unit. (It may be called the cardiac care unit.) When you wake up, you ll have a breathing tube in place. You ll also be connected to several machines. This is normal. These machines are used to monitor your recovery. As you become alert and stable, the breathing tube will be removed. Your Hospital Recovery When you no longer need intensive care, you ll be moved to another room. At this point, you may begin eating and taking oral medications. As soon as possible, you ll start moving around and walking. This helps boost muscle strength. It also improves blood flow and helps to aid healing. You ll be able to go home when your doctor feels your condition is stable. Have an adult family member or friend prepared to drive you home. Also, arrange for an adult to stay with you for a few days after you get home. When to Call the Doctor After bypass surgery, any of these warning signs could signal heart problems. Call your doctor if you have: Severe shortness of breath Unexplained bleeding or bruising Increasing drainage or redness around chest or leg incisions Palpitations or racing heartbeat Return of angina, or any unusual pain Fever of 100.4 F (38 C) or higher A weight gain of more than 2 pounds in 1 day, or more than 5 pounds in 1 week, or other amount as instructed by your doctor 13
Recovering from Your Procedure Whether you had a catheter-based procedure or bypass surgery, follow all your healthcare team s instructions. This is the best way to help your body heal. You re likely to gain a little more energy and strength each day. If cardiac rehabilitation is prescribed, be sure to go. A rehab program can help you feel better faster and reduce your risk of future heart problems. Back at Home The speed of your recovery will depend on which procedure you had. Also, each person recovers at a different rate. For best results, be sure to: Take all medications as prescribed. Take the exact dose as often as instructed. Don t stop any medications without your doctor s okay. Do tell your doctor if you have any problems after taking medications. Upset stomach, diarrhea, or skin rash might occur. Take care of all incisions as directed. You may be told to wash incisions with warm (not hot) water and soap. To help prevent infection, don t use ointments or lotion. Shower or take sponge baths if you had bypass surgery or a catheter was inserted in the groin. Don t take a tub bath until your doctor says it s okay. Increase activity over time. Ask your doctor when you can resume lifting, driving, work, exercise, and sex. See your doctor as often as directed. This helps assure your future health. If Symptoms Return No matter which procedure you had, contact your doctor right away if symptoms such as chest pain or discomfort return. 14
Understanding Cardiac Rehab Your doctor may prescribe a cardiac rehab program. These programs provide a structured way to improve heart health. You ll work with a team of specialists. These may include doctors, nurses, physical activity specialists, dietitians, and counselors. Cardiac rehab can help you feel better now. It also can teach you how to improve your health for the rest of your life. In Cardiac Rehab Cardiac rehab can help you learn how to manage your risk factors. Sessions can be held in a hospital, a clinic, or a doctor s office. Program specifics may include: Physical activity. You ll learn safe ways to be active and exercises to strengthen your heart. Nutrition education. Working with a dietitian, you ll learn to make heart-healthy food choices. Counseling. You ll get help dealing with the emotional aspects of heart disease and its treatment. Family education. If they want, family members can learn with you. That way, they can help you stick with your new skills and knowledge after the rehab program ends. You will work with a therapist to learn safe ways to be active. Exercise helps strengthen your heart muscle. 15
Work with Your Doctor Coronary artery procedures offer many benefits. They can be used to diagnose heart problems and treat problems that are found. Talk with your doctor to learn why a coronary artery procedure may be the best choice for you. Ask if other tests or treatments might be tried first. Together, you and your doctor can make the best plan for you and your heart. Change for Your Health Make long-term, heart-healthy lifestyle changes. This will reduce your chances of forming new artery blockages. If you smoke or use other forms of tobacco, quit. This may be the most important thing you do for your heart. Expect to take certain medications for the rest of your life. Lose excess body weight. Ask your doctor for help, if needed. Be physically active for at least 40 minutes, 3 to 4 days a week. Manage your heart-related risk factors. These include diabetes, high blood pressure, unhealthy cholesterol levels, and obesity. Also available in Spanish TAKE OUR PATIENT SURVEY. Help us help other patients. Please visit www.kramesurvey.com to provide your feedback on this booklet. This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem. 2013, 2014, 2015 The StayWell Company, LLC. www.kramesstore.com 800.333.3032 All rights reserved. Made in the USA. 11965 1509