Interventional Cardiology in Coronary Pathology

What is Interventional Cardiology?

Interventional Cardiology is the subspecialty of cardiology dedicated to the diagnosis and treatment of atherosclerotic disease of the coronary arteries and some structural heart diseases by means of very fine tubes, called catheters. Unlike surgery, which requires a wound and opening the chest to reach the heart, in interventional procedures these catheters are inserted through an artery or vein in the leg or arm. The catheter accesses the heart by following the path of the artery/vein and allows the diagnostic and/or therapeutic procedure to be performed on its arteries and structures. Since this type of procedure does not involve an open heart, it is considered minimally invasive surgery. Being a sub-specialty of cardiology, the cardiologist receives special training in the use of catheters, contrast media, fluoroscopy and in the techniques of balloon angioplasty and coronary artery stent implantation, which is the most frequently performed procedure.

What types of procedures are there?

We can classify interventional cardiology procedures into two main types: coronary and non-coronary, depending on whether they focus on the diagnosis and treatment of atherosclerotic coronary artery disease or not.

Coronary procedures consist of diagnosing the presence of a disease of the coronary arteries, which are the arteries that supply the blood so that the heart can function normally and which, if diseased, can cause angina or infarction. In addition to the possibility of diagnosing coronary artery disease, coronary procedures offer the possibility of treating it. The treatment is based on the introduction into the diseased artery of a metal or polymer mesh, called a stent or scaffold, which widens the diseased segment and keeps the vessel open. This particular procedure, called coronary angioplasty, represents 90% of all interventional cardiology procedures.

Non-coronary procedures consist of the treatment of structural heart diseases, such as the closure of anomalous communications between two parts of the heart (closure of atrial septal defect, patent foramen ovale, transcatheter aortic prosthesis implantation or reduction of mitral valve insufficiency through the implantation of a clamp, called “Mitraclip”). In particular, percutaneous aortic prosthesis implantation is a very promising procedure in the treatment of aortic stenosis without the need for cardiac surgery and, although it is currently performed in patients with high surgical risks, it promises to be extended to the treatment of younger patients in the coming years.

How are coronary artery problems treated?

Coronary artery problems are treated with a procedure called percutaneous transluminal coronary angioplasty (PTCA), which is a very effective form of non-surgical treatment for patients with certain forms of coronary artery disease. It basically consists of dilating the narrowing (stenosis) located in the arteries that supply the heart (coronary arteries), which have been previously identified by diagnostic cardiac catheterization. These stenoses imply the existence of obstructions in the coronary vessels that prevent blood from accessing the heart normally, which can lead to angina pectoris or even a heart attack. The mechanism to solve the coronary obstruction with PTCA is highly variable. In almost all cases, a very thin catheter with a balloon at the tip is placed across the stenosis. Inflation of the balloon under pressure ruptures the plaque and relieves the stricture. Very often, to successfully complement the procedure, the placement of a metallic or polymeric mesh, called a stent or scaffold, which supports the vessel walls and guarantees a good result, is required. The approach (puncture at the groin/arm/elbow) is identical to that used for catheterization, although the catheters are generally of a slightly larger caliber. Angioplasty is usually an alternative procedure to diagnostic catheterization, although it can be performed immediately after catheterization and should be considered.

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The stent/scaffold (intracoronary metallic/polymeric mesh) is an integral part of angioplasty treatment and consists of a thin metal or polymer tube, which implanted inside the coronary artery at the site of the dilated obstruction, provides support to the arterial wall and helps to keep the artery open.

Since the description of the balloon coronary angioplasty technique in 1977 by Dr. Andreas Gruentzig, percutaneous coronary balloon angioplasty has made an enormous impact and has established itself as a minimally invasive alternative to bypass surgery. After the introduction of the first stent to prevent closure of the coronary artery, which had already been balloon dilated, in 1982 by Dr. Andreas Gruentzig, the first balloon angioplasty was performed by Dr. Andreas Gruentzig. Ulrich Sigwart, interventional cardiology has been advancing rapidly. Over the years, stent design has improved, reaching its fourth generation today with polymeric stents that are completely resorbable within two years of placement, compared to metallic stents, which remain inside the artery for the rest of their life.

Risk factors for coronary artery disease

Risk factors for coronary artery disease are divided into two categories: modifiable and non-modifiable. Non-modifiable risk factors are age and the fact of being male or female, and are factors that cannot be influenced by any lifestyle or medication. On the other hand, modifiable risk factors are factors on which physicians and, above all, patients can act, with changes in lifestyle or medication, to bring them under control and thus reduce the risk of suffering from heart disease, both in primary and secondary prevention. These modifiable risk factors are high blood pressure, high cholesterol, smoking, diabetes, obesity and a sedentary lifestyle. It is important to point out that maintaining a healthy lifestyle can in some cases bring these risk factors under control without the need to take any medication. This requires abstaining from tobacco and alcohol, daily physical activity (walking 30 minutes/day), a diet rich in fruits and vegetables and low in fat (especially avoiding sausages and red meat), and maintaining an optimal weight. In cases where, despite a healthy lifestyle, these cardiovascular risk factors cannot be controlled, there are currently highly effective drugs such as antihypertensives and statins, for example.