Treatment for CHD and heart attack include drug treatment, angioplasty and stent placement, and coronary artery bypass graft (CABG) surgery. Treatment for ischemic stroke is similar to treatment for CHD and heart attack, while treatment for hemorrhagic stroke seeks to prevent uncontrolled bleeding in the brain.
Drug Treatment: Angina
Stable angina can be treated with drug therapy to prevent or reduce ischemia and to minimize symptoms. Five types of drugs are used: nitrates (including nitroglycerin), beta-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and antiplatelet drugs.
- Nitrates act very quickly to dilate blood vessels and last for a period of about half an hour.
- Beta-blockers limit the increase in heart rate and blood pressure during exercise and so reduce the demand for oxygen.
- Calcium channel blockers prevent blood vessels from constricting, counter coronary artery spasm, and reduce blood pressure.
- ACE inhibitors don't treat angina itself, but can reduce the risk of heart attack and of death due to CAD.
- Antiplatelet drugs (including aspirin) modify platelets so that they don't clump and adhere to blood vessel walls.
Drug Treatment: Cholesterol
Preventive drug therapy with statins is being increasingly recognized as an effective way to combat atherosclerosis. Statins are a class of drugs that lower the level of LDL-cholesterol in the blood by inhibiting its synthesis in the liver. Statins also reduce inflammation, an important component of plaque formation, as indicated by lowered levels of C-reactive protein (CRP). CRP is the most dependable measure of systemic inflammation. Statins slow the formation of new plaques, and aggressive therapy with statins has even been found to reduce the size of existing plaques. What's more, statins may stabilize plaques and make them less prone to rupture and form clots.
Drug Treatment: Heart Attack
A number of different drugs may be administered in order to clear arterial blockage during a heart attack, including thrombolytic or fibrinolytic ("clot-busting") drugs:
- Aspirin helps reduce the size of the clot
- Clopidogrel, another blood thinner, may be given instead of, or in addition to, aspirin
- Anticoagulants, such as heparin, prevent the formation of additional blood clots
- Oxygen helps minimize tissue damage
- Beta-blockers slow the heart down so it doesn't have to work so hard
- Morphine has a calming effect and reduces the workload of the heart
- Nitroglycerin relieves pain by reducing the heart's workload and possibly by dilating the arteries
- ACE inhibitors can reduce heart enlargement by lowering blood pressure
Clot-busting therapy has been shown to reduce death from heart attacks similarly in men and women. However, slightly more women than men suffer from strokes as a complication of the treatment.
Angioplasty and Stent Placement
Angioplasties are frequently performed after an angiogram has detected a blockage in a coronary artery, sometimes directly following the angiogram. Angioplasties may be done to expand a partially blocked artery or during or after a heart attack.
During an angioplasty, a small balloon at the end of the catheter is inflated, sometimes several times, to widen the artery. This typically reduces blockage from 70-90% to about 20-30%. When the artery is widened, a stent, a tiny coil of wire mesh, only about three quarters of an inch long, is often inserted into the artery to keep it from narrowing again. The balloon is again inflated and the stent springs open. The balloon catheter is removed and the stent remains permanently in place. Drug-eluting stents are coated with medication and may be used to prevent clot formation and restenosis (renarrowing of the artery).
Angioplasty, when used for acute heart attack, is as effective for women as it is for men, but women have a higher rate of complications in their blood vessels and of death. This may be due to women's older average age at time of treatment, smaller blood vessels, and greater severity of angina. Long-term outcomes, however, are similar for men and women.
Angioplasty and stenting are commonly used treatments for the clogged or blocked arteries of CHD. However, they aren't necessarily the best option for every woman, because women tend to have more diffuse plaques than men, that is, plaques that are spread out as an even layer along artery walls. Angioplasty and stenting treat distinct plaque formations in localized areas, the type of plaques that men tend to have.
Coronary Artery Bypass Grafting (CABG) Surgery
Coronary artery bypass graft (CABG) surgery is performed to detour blood flow around blocked arteries. It's used for patients who haven't responded to therapy with medication and who aren't good candidates for angioplasty procedures, generally because they have significant narrowing in multiple coronary arteries.
There are a number of different forms of CABG surgery, but they all involve removing a blood vessel from a different part of the patient's body for use as a graft. The graft is connected to areas before and after the blocked area of the coronary artery so that blood flows around (bypasses) the blockage. This restores blood flow to the affected part of the heart and relieves chest pain and other symptoms.
CABG surgery may be preferred for patients who have a bleeding disorder or who have had recent surgery or a stroke, and those with very severe arterial disease. The immediate mortality rate is higher for women than it is for men, and this has been attributed to women's older average age at time of surgery, smaller blood vessels, and greater severity of angina (as for angioplasty). However, long-term survival and rates of recurrent heart attack and need for reoperation are similar in women and men.
Risks of Surgical and Nonsurgical Procedures for CHD
- Angioplasty and Stenting. Risks include stroke, allergic reaction to dye, bleeding or infection at the catheter insertion site, damage to a heart valve or blood vessel, kidney failure, arrhythmias, and blockage of blood flow to heart.
- CABG Surgery. Risks include death, heart attack, bleeding, stroke, arrhythmia, infection, and problems with memory, comprehension, and concentration.
Treatment for Stroke
The main goal in treating ischemic stroke is to restore blood flow to the brain. Treatments include medications as well as surgical and nonsurgical procedures.
- Aspirin. An antiplatelet medication that decreases blood clot formation by preventing the smallest blood cells (platelets) from sticking together. Aspirin is the best treatment immediately after a stroke to prevent further stroke. Ischemic stroke patients are typically given aspirin in the emergency room.
- Heparin and warfarin (Coumadin). Anticoagulants that help prevent clots from forming
- Tissue plasminogen activator (TPA). A potent clot-busting drug that may improve chances of recovery for some patients
Surgical and nonsurgical procedures:
- Carotid endarterectomy. This surgery aims to reduce the risk of future strokes. The carotid arteries are large arteries that supply blood to the brain and run up along either side of the neck. In a carotid endarterectomy, an incision is made in the carotid artery, and plaques that have formed there are removed using a dissecting tool.
- Angioplasty and stents. An option that may be appropriate if the patient can't undergo surgery. A balloon-tipped catheter is inserted in an artery, usually near the groin, and threaded up to the narrowed artery. This may be either a carotid artery or a brain artery. The balloon is inflated to widen the artery, and a stent, a tube reinforced with a metal mesh, is left in place to keep the artery open. Umbrella stents have tiny, umbrella-like filters attached to one end to catch any debris that may have been loosened by the procedure. The umbrella is removed after the procedure is completed.
Treatment for hemorrhagic stroke seeks to isolate the aneurysm. Techniques include:
- Aneurysm clipping. A tiny, permanent clamp is placed at the base of the aneurysm, cutting it off from the blood supply in order to keep it from bleeding. If the aneurysm has recently ruptured, the clip may be used to prevent rebleeding.
- Aneurysm embolization, or coiling. A catheter is threaded into the aneurysm, and a tiny coil is pushed through it and deposited inside the aneurysm. The coil causes clotting and so seals off the aneurysm from connecting arteries.
- Surgical arteriovenous malformation (AVM) removal. AVMs are areas of malformed blood vessels that lack capillaries. They may be surgically removed from accessible parts of the brain, reducing the risk of hemorrhagic stroke.
Risks of Surgical and Nonsurgical Procedures for Stroke
- Carotid Endarterectomy. There is a risk of stroke following a carotid endarterectomy. There is also a risk of restenosis (reblockage) of the artery, and of temporary nerve damage.
- Cerebral Surgery. If a cerebral aneurysm is small, less than 1/2 inch (1 cm), then the doctor may advise only monitoring to detect growth or onset of symptoms. Cerebral surgery is risky. It can pose some of the same dangers that a ruptured aneurysm can, if the aneurysm ruptures during surgery and bleeding cannot be controlled: stroke, disability, and death.
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