Modification of the lifestyle
It is mandatory to quit smoking and an aggressive risk factor modification is warranted: the blood pressure should be normalized in case of hypertension. Lipid lowering drugs have to be prescribed to normalize high blood levels of cholesterol. Glycemic control in diabetics is important.
In all cases, it is recommended to adjust the body weight and to perform daily exercise.
Drugs
 Antianginal drugs
Their aim is to prevent or attenuate angina pectoris episodes.
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 Nitroglycerine and its derivatives |
Nitroglycerine is used primarily to treat angina pectoris episodes, in the
form of tablets to be chewed or a spray; it acts almost immediately
(the episode disappears
after 1 to 2 minutes). Any person suffering from coronary artery disease is advised
to always have some readily available and to check the expiry date marked on
the packet.
If the episode does not attenuate quickly after taking a tablet or using a spray,
you can take another tablet or use the spray again, but no more than that.
Nitroglycerine derivatives can also be used as a “long term” antianginal
treatment. They are then prescribed in so-called “delayed action” forms
which are released gradually into the body, or in the form of patches stuck on
the skin.
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Beta-blockers |
Beta-blockers reduce the heart's workload by reducing the resting heart rate
and above all during exertion.
They are also used in the treatment
of hypertension and sometimes heart failure.
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Calcium channel-blocking agents |
These drugs reduce the passage of calcium in the cells and have a relaxing effect
on the artery walls: the result is both a dilatation of the coronary arteries
and a fall in blood pressure. Some can also reduce the heart rate.
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Metabolic agents |
Thanks to a specific metabolic mechanism of action, these agents prevent
symptoms of angina and improve ergometric parameters, thus offering a reliable
protection to all coronary patients.
These agents reduce the metabolic damage caused by the lack of
oxygen in the tissue.
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Other antianginal drugs |
Other drugs are available or are being studied, this being an area where the research departments
of pharmaceutical laboratories are very active.
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Whatever antianginal drug has been prescribed, you
must never stop the treatment abruptly, particularly when taking beta-blockers.
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Secondary prevention
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Antithrombotic drugs |
They prevent the formation of blood clots in the coronary arteries or they can even dissolve
the clots that have caused an infarction.
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- Platelet aggregation inhibiting
drugs |
Some of these drugs are very powerful and are administered via an intravenous
perfusion during acute coronary syndromes. Others taken orally
are easily digestible.
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- Oral anticoagulants (anti-vitamin
K) |
These drugs prevent the formation of blood clots. They act on the blood-clotting
by preventing certain vitamin K-dependent factors from forming: this explains
their gradual action over time
and the necessity of a strict control to avoid bleeding. The many interactions,
either with other drugs (aspirin and non steroidal anti-inflammatory drugs),
or with the person’s diet
(green vegetables, cabbage… foodstuffs containing vitamin K), necessitate
meticulous and restrictive controls by means of regular blood tests.
These are not indicated in an emergency situation but are sometime used for the
follow-up of a myocardial infarction.
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- Anticoagulants administered
by injection |
These products, heparin and its derivatives, are used during hospitalisation
in the first few days after an infarction, to treat patients suffering from unstable
angina or those undergoing an angioplasty or a coronary bypass, (or in the case
of a venous disease). Patients must be kept under regular observation with blood
tests. Some forms of heparin (low molecular weight heparin) can also be
used outside the hospital environment; injections are given by a nurse but are
also
self-administered after a short learning period.
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Cholesterol lowering drugs |
These drugs, such as statins, lower bad cholesterol in the blood
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Drugs under investigation |
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The EUROPA study investigated
the use of an ACE-inhibitor, perindopril, in secondary
prevention of Coronary Artery Disease irrespective of the patients’ risk.
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After suffering an infarction many other kinds of drugs can be
used, in particular to treat heart failure and to modify your risk
factors.
Interventions on the coronary arteries
Coronary bypass
The principle consists of creating a bridge to bypass the constricted area of
the coronary artery. Two kinds of bypasses can be used:
in a vein bypass, a vein is taken from the leg and one side is attached to
the aorta and the other to the coronary artery further up from the constricted
segment.
arterial bypasses generally use the internal mammary artery which usually
supplies blood to the wall of the thorax. This artery is by nature almost always
healthy and it is not indispensable for the wall of the thorax. It is deviated
from its usual route and is implanted on the coronary artery beyond the constriction.
In general, a coronary bypass is only used for patients who have several coronary
arteries that are affected. The surgeon then implants several bypasses during
the same operation.
The length of hospitalisation after a bypass is about a week,
with a spell in an intensive care unit immediately after the operation.
Techniques have been developed over the last few years where the
bypass is carried out without stopping the heart (so called “beating
heart” bypasses) and sometimes using videosurgery where only
a small opening is made in the thorax.
Coronary angioplasty or coronary dilatation
Percutaneous coronary angioplasty or coronary dilatation is used to treat
stenoses without having to operate.
The intervention starts like a coronarography, the cardiologist
passes a very flexible metal guide through the constricted area of the
artery. Along this guide is then passed a tube with an inflatable bladder
on the end. When the bladder has crossed the constricted area, it is
inflated with liquid for a few seconds to a few minutes to compress the
atheromatous plaque which is obstructing the artery and dilate the constricted
segment.
If the result is inadequate, further inflations can be practiced.
To obtain the best result immediately, it is often necessary to complete
the dilatation by implanting a small tube or stainless steel lattice called
a “stent” or coronary “endoprosthesis”, which is
applied against the internal wall of the artery by inflating the bladder.
The stent is left in place in the artery to support the wall.
Coronary angioplasty is a less invasive “revascularisation” technique
than a bypass and it does not even require a general anaesthetic. A recurrence
of the stenosis can still occur within the 4 to 6 weeks following the dilatation.
This risk has however lessened considerably thanks to the use of a new
generation of “active” stents coated with a drug which prevents
restenosis.
Stenosis: constriction of an artery
Ischaemia: circulatory deficiency of the blood in a tissue
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