Cardiac Treatment and Patient selection

We all know from research and increasing incidence of heart attack among our population that there is a need for screening the population. But at the same time certain questions come up – What is meant by a screening test? What is the best method of screening? Do we need to subject all people to an invasive angiogram to screen them? What are the available methods of screening ? what are the costs involved in screening tests? All of these are multitudes of questions asked by various people. And often a single sentence answer – "These medicines will do", or "your TMT is negative so medical management is fine", or "lets do an angiogram to be sure" is given. Understanding the basic facts of the disease is the key to prevent further disease progression and effective treatment. These questions and answers could probably give you a better idea on What is evaluated ? & How do you actually prevent disease?

Who is at risk ?

A person at an increased cardiac risk is someone who has a Family History of heart disease, Age > 40 years, Smoking, Blood Pressure (Hypertension), Diabetes, Cholesterol, No exercise, Increased weight, Increased waist girth, Low HDL cholesterol, Calcium deposition in your heart vessels ect. All of these people are at a higher risk for heart disease compared to others without such risk factors. If we were to look at this we might have to look at 80% of our population as susceptible. So who actually need to be screened is the question?

What is the method to pick the most susceptible people?

Ask your self – Do you have more than 3 of these risk factors. Secondly do you have symptoms – Chest pain, Breathlessness, swelling over feet, discomfort in the chest while straining, have your doctor mentioned resting ECG changes in a routine ECG ect. Based on these you are categorized into three groups 1. Asymptomatic at risk group 2. Symptomatic Group 3. Previous Heart attack has occurred (Documented or Not Documented)

Until today Exercise Tread mill test is being used as the best, the most available and economical method in picking potentially susceptible people. How is it done?

To conduct an exercise Tread mill a patient is asked to walk on a treadmill for 12 to 15 minutes after fixing ECG leads on the chest. During the tests the ECG is continuously monitored by a trained physician or a cardiologist. Many centres do adopt to doing these tests by trained TMT technicians. The tests assesses the ECG changes during the time graded stress is given to the patients heart. The tests can be classified into strongly positive, Intermediately positive and Mildly positive. If you are strongly positive (stage 1 and 2 ) the recommendations are an “Invasive Catheter Angiography” since the likeliness of a significant lesion is very much possible and curative treatment can be done along with the same procedure. The utility of an invasive angiography is to decrease the cost by opting for a “Stenting” in the same sitting and also to avoid further procedures. If it is a screening test to evaluate what mode of treatment should a patient adopt – meaning “treatment by Stenting” or “ treatment by Bypass Surgery” – the question is again asked why an invasive procedure for screening alone. But if you are moderately or mildly positive – patients are referred to stress thallium testing or CT angiography to know if the lesions are functionally significant or are involving more than 75% cross sectional diameter. The gold standard for assessment of functional significance was using a Doppler Probe across the said blockage while doing angiography and calculating something called FFR “Fractional Flow reserve”. Long years of research evaluating numerous patient data have shown us that lesions which have an FFR value less than 0.75 only need stenting and those > 0.75 can very well with medical management. The cost for evaluating an FFR is very high during an angiography procedure because of the cost involved in disposable Doppler probe usage. The only other functional assessment tool or data which could be put to clinical use in India as in the Western World is evaluation of these patients by either “ Stress Myocardial perfusion Scan or Stress Thallium” and “calculating cross sectional stenosis by “ CT Angiography , QCA (Quantitative Coronary Angiography), or typing the vulnerability of the plaque”.

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