Why do you need a coronary angiogram?
To find out any problems you may have with the arteries that supply blood to the heart muscle. This procedure happens in the cardiac catheterisation laboratory using X-ray screening and takes around 30 minutes.
Angiogram pictures are taken to begin with and, depending on what they show, the treatment options most often are: medical therapy with tablets, angioplasty and stents (PCI) or coronary artery bypass grafts (CABG).
As part of your angiogram procedure or before a PCI we may need to gather more information about your arteries. We can gather this by using other techniques called pressure wires, IVUS and OCT- these will be discussed in more detail during your pre-assessment.
The remainder of this information explains in further detail angioplasty and stent treatment. If you should require either medical therapy or CABG both your consultant and nurse will discuss this with you after your angiogram procedure.
Why might you need a PCI procedure?
The aim of a PCI procedure is to widen any narrowing in the arteries of your heart. This is done by passing a balloon into the narrowed part and inflating it to stretch it open. This increases the blood flow through the artery, helping to improve your angina.
The main reason for a planned (elective) PCI is to reduce your angina not to reduce the risk of heart attacks.
The PCI does not cure your coronary artery disease but does treat your symptoms. After the procedure it is important that you follow the advice you will be given about smoking, diet, exercise and cholesterol.
What does this treatment involve?
The procedure usually takes 60 to 90 minutes. The procedure involves passing a fine plastic tube (a sheath) into your arm or groin artery via a small puncture.
A local anaesthetic is used to numb the area. A long fine tube is then passed through the sheath. This allows a wire to be passed into the artery where the narrowing is. The doctor then passes a fine balloon over the wire. The balloon is inflated, pushing aside the fatty tissue that causes the narrowing, opening the artery. It is not uncommon to have some, short lived, angina type symptoms at this stage and pain relief medication can be given if required.
Coronary artery stents are tiny wire mesh tubes that are used to widen narrowed arteries during a PCI. The stent will stay inside your artery forever and slowly becomes part of the artery wall.
Occasionally the balloon alone produces a sufficiently good result and then a stent is not required.
Drug-eluting stents are coated in a drug that reduces the chance of the artery from becoming narrow again after the procedure.
Once implanted into the artery, the drug is slowly absorbed into the tissues surrounding the stent. The choice of stent is based on individual requirements, although national guidance is available to help doctors decide (NICE 2008). This can be discussed in more detail with your nurse or doctor.
After the procedure a band is placed around the wrist to apply pressure and is gradually released. If the procedure is through the groin a pressure device or closure device can be used and will be monitored by the nursing staff on the ward after the procedure. This is to reduce the chance of the artery bleeding.
After the procedure if all the routine checks are fine, you feel well and the PCI has been straightforward it is often possible to discharge you the same day.
If you experience any problems, you will stay overnight and normally be discharged the next day. It is likely that your doctor will give you a course of tablets (for example clopidogrel, prasugrel or ticagrelor) to take before and after the procedure. These tablets are an ‘anti-platelet’ which is taken along with aspirin.
It is currently the best treatment to prevent a clot forming at the site of the stent. You will be given your own supply of these tablets to take home. The duration of treatment varies from patient to patient. It may be as short as one month, or as long as twelve months. In a few patients, the doctor may recommend that you stay on this treatment lifelong.
The benefits of PCI?
Usually the procedure will improve or totally relieve your symptoms of discomfort and may improve your breathing. However, if your heart muscle is damaged from a previous heart attack then your breathing may not improve much. After the procedure you may have some tablets stopped but there is always a need to stay on some tablets.
The risks of PCI?
Any procedure or operation has an element of risk and a PCI is no exception. There is a small risk of heart attack or stroke during the procedure. This occurs in less than 1% of patients. Occasionally during the procedure the artery or a small side branch may become narrow, block completely or tear. This may require emergency coronary artery bypass surgery if balloons cannot repair the blockage or tear. This occurs in less than 1%. There is a less than 1% chance of dying during your procedure (fewer than 1 in 500 people).
It is very important to understand that although the success rate of PCI is very high there is a risk of the artery renarrowing in the area that has been opened. Overall, there is a one in ten chance over the first six months following the procedure that your symptoms may return. The chances of this vary from patient to patient. If this does occur, it can be possible to treat this with further balloon or stent procedures.
Alternatives to PCI
If PCI is particularly complicated, or if you feel unhappy to go ahead with the procedure, you have the option to continue with medical treatment. Alternatively, if your artery disease is severe, you may require coronary artery bypass surgery. You will have the opportunity to discuss alternatives further with your doctor.
Possible complications of PCI
There is a small chance that you will experience problems within the groin or arm. This usually means a small bruise, which will disappear following rest, or a much larger bruise called a haematoma. This is a collection of blood under the skin which may require prolonged bed rest and, or a pressure dressing. Very occasionally it requires a scan and injection to heal the small hole in the artery.
Sometimes you may have a reaction to the dye used during the procedure. This usually takes the form of mild nausea, a minor skin rash or itching. If you have had similar reactions previously or have specific allergies please inform the doctor or nurse. Rarely, the rhythm of the heart can change but this is usually easily corrected.
Advice following your PCI
Most people experience no problems after their angioplasty but if you have any worries please contact either the ward or the specialist nurse team on 01642 854922.
You will be seen by the specialist nurse and, or cardiac rehabilitation team after the procedure and advised when you can drive, return to work and fly. Other general activities and exercise will also be discussed.
If you have a stent inserted, you will be given an anti-platelet medication. Please make sure you finish the full course following the procedure. This medication is taken to reduce the risk of blood clots forming within the stent and is important because clot formation may lead to a heart attack.
If you do develop a red rash or itching, it is probably due to the dye and not due to any medications. Do not stop the anti-platelet tablets. If the rash persists or is troublesome, steroids and antihistamine tablets could be given by your GP. If the rash remains a problem despite treatment, your GP can contact the hospital on the number below.
You may experience some slight bruising around the catheter entry site. This is normal as long as it is not swollen, lumpy or painful.
Please contact the ward, specialist nurse team or your GP if:
- The catheter entry site starts to bleed and it continues for any length of time after you have applied pressure to the area.
- You develop any unusual pain, swelling or hard lumps at the entry site.
- There is any change to the colour or temperature of the leg (or arm if used) where the catheter was inserted. there is any abnormal rise in your temperature.
This information is designed to explain the pros and cons of PCI. The benefits and risks can differ from person to person. When you see the doctor or nurse they will discuss the findings with you. This is to agree any further treatment you may need, which can differ from the information given on this sheet. You will be given time to ask any questions you or your family may have.
As we are a teaching hospital you may be asked to take part in a clinical trial. If so, then follow up from procedures may be slightly different and would be fully explained during the consent process for taking part.
The organisations below can provide more information and support for people with coronary artery disease. NICE guidance is also available for drug eluting stents.
- Action Heart – Telephone 01384 292233 or visit: www.actionheart.com
- British Heart Foundation – Telephone 08450 708070 or visit: www.bhf.org.uk
- NHS – visit: www.nhs.uk
- NICE – visit: www.nice.org.uk/aboutguidance
South Tees Hospitals NHS Foundation Trust would like your feedback. If you wish to share your experience about your care and treatment or on behalf of a patient, please contact The Patient Experience Department who will advise you on how best to do this.
This service is based at The James Cook University Hospital but also covers the Friarage Hospital in Northallerton, our community hospitals and community health services.