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What’s new in the field of coronary artery disease?

Coronary artery disease (CAD) and strokes are the leading causes of death and morbidity in the Western world. The scale of this problem is enormous when one also refers to the developing world, such as Africa, where chronic diseases including CAD are replacing infectious diseases as the leading cause of premature death. Heart disease also accounts for the premature death of 2.25/100,000 women giving birth.

Study

The Framingham Health Study has consistently shown that smoking, diabetes, hypertension, cholesterol and male gender cause cardiovascular disease. Despite this knowledge, the persistent high morbidity reflects poor risk factor management and lack of investment in preventative medicine, especially when 80 per cent of all hospital admissions in Ireland and the UK are still due to chronic diseases. Too many people still smoke, eat too much, are inactive, drink too much and don’t take care of their health.

In the Framingham study of over 200 patients, stress was associated with increased activity in the amygdala of the brain, in bone marrow and spleen by PET scan and this led to the hypothesis that autonomic and inflammatory mechanisms may be responsible. Stress is a very important risk factor, given the increasing levels that we are all aware of. Interestingly, the adverse cardiac risk from stress was independent of traditional factors such as weight, blood pressure, diabetes and smoking.

Other risk factors that are hugely important are obesity, inactivity, poor sleep and mental ill health/depression, to name but a few. Inflammatory diseases, such as arthritis and lupus, also increase the risk for heart disease.

Family history of heart disease is very important, even if the relative(s) had lifestyle issues, such as smoking.

Assessment

Traditionally, a good history, physical examination, cholesterol panel, body weight/waist circumference, HbA1C and blood glucose would suffice. In turn, a risk score calculator (HEARTSCORE/ Framingham) can be used to define 10-year risk for heart disease.

I find that it is critical to take a thorough history from patients.  (‘If you take a good history from a patient, they will tell you what is wrong; if you take a better history from a patient, they will often tell you how to treat it.’)

There are often subtle symptoms that point to heart problems, especially in women, who have such an array of symptoms that may reflect heart disease. Fatigue, chest pains at night or when at rest, back pains and sweating are some symptoms that often relate to heart disease.

In conjunction with atherosclerosis of coronary arteries, it is an appropriate time to check for cerebrovascular and peripheral vascular symptoms, including dizziness, heart palpitations or any suggestion of atrial fibrillation (AF).

Patients with hypertension, diabetes and heart failure, or over 60 years old, are most likely to develop AF and current novel oral anticoagulants (NOAC) therapy for those with CHADSVASC scores of two or over significantly reduces stroke risk. Interestingly, while bleeding risk is actually low on a NOAC, these patients ultimately die from heart disease, heart failure or diabetes, so these risk factors need ongoing attention.

Newer tools for risk assessment are accessible online — mobile phone apps such as Kardia AliveCor, CHADSVASC calculators, and CAD risk calculators to help patients and doctors define and manage risk. In addition, patients are accessing this information online even before they see the doctor. The medical information is vast, so trustworthy websites are really important for patients wanting access to information.

Tests

Exercise stress tests for patients are sensitive for detecting heart disease but not specific, especially in women over aged 60 years. So many patients get abnormal stress tests that invasive testing reveals normal arteries or in younger, often fitter individuals with good exercise capacity, there is great ability to beat exercise tests and still have coronary artery disease.

Pharmacological stress tests, including perfusion scans and stress echocardiography, are liable to similar false positive and negative outcomes and are still very subjective in interpretation. A stress MRI scan is excellent for measuring perfusion and validating stress tests. I use MRI to assess for ischaemia in patients with chest pain symptoms with abnormal and normal angiograms and I also refer athletes for cardiac MRI.

Coronary angiography is the gold standard for identifying coronary artery disease and treating with stents. However, it is invasive and carries a risk of bleeding, heart attack and stroke. Patients who have blocked arteries can be treated with stents, surgery or medication. In several cases of atypical symptoms or intermediate disease, pressure wire measures with Fractional Flow Reserve (FFR) are invaluable at deciding whether stenting or medical therapy is most appropriate. FFR data is prognostic, so that a normal FFR in a patient with chest pain suggests that pain is not due to coronary artery disease. Similarly, symptoms in patients with abnormal FFR who are treated with stents or surgery will usually resolve when treatment is guided this way.

CT coronary angiography is the ‘new imaging kid on the block’, even though it has been around for 10 years. Innovations in CT technology now mean that accuracy and resolution have improved to a level that you can see arteries clearly and in almost all individuals.

CT coronary angiograms are very practical to rule out coronary artery disease and to identify early plaque formation (which can reinforce medication compliance for patients).

The major advantage with CT is, as patient or doctor, you know if you have a case of coronary artery disease or not. Given the poor specificity around exercise stress testing, CT coronary angiography is a much more accurate way to assess for coronary artery disease. CT is recommended for risk assessment in patients with two or more risk factors for heart disease and is becoming an attractive way for patients to undergo an angiogram compared to an invasive option.

Soon, it will also be possible to measure blood flow (like the FFR during an invasive angiogram) as part of the same test, which will make CT a complete ‘all-in-one test’. The National Institute for Health and Care Excellence (NICE) has recently approved software to measure CT FFR as standard of care for non-invasive angiography in UK.

Management

I have established a health and wellness programme to help prevent heart disease and strokes through nutrition and lifestyle interventions (RK Cardiology Healthy Living). I find that so many patients will not change their lifestyle unless closely guided through it.

We have helped patients in terms of exercise, nutrition, stress and mental wellbeing. Most have lost and sustained over two and three stone in weight; several have reduced tablet requirements such as insulin, blood pressure tablets and statins. In some cases, we have reduced atherosclerosis on follow-up angiography. Therefore, continuous lifestyle measures work on multiple levels.

Newer aspects of lifestyle treatment include sleep clinics, food supplements to counteract inflammation, hormone replacement for men and women and various exercise programmes, including DNA-guided diets and exercise regimens. Given the link between heart disease and stress, there is growing interest in the corporate world in personalised health and wellness programmes for employees.

Technology

Wearable technologies, such as Fitbit, Apple watch and Microsoft Band offer patients ways to measure heart rate, steps and to share data and these technologies have also been integrated into healthcare platforms.

Examples include Vtuls, a platform of health coaches that helps people lose weight, exercise or manage stress; Omada Health, a diabetes management platform; and Fruit Street Health, an obesity management platform with dieticians where patients share weight and food intake measures from wearables and have consultations by video.

Another development involves the use of drones to deliver medications to people but also to deliver a defibrillator to the site of a cardiac arrest. Alternatively, if one witnesses a cardiac arrest, one can call Amazon Echo and Alexa, the virtual assistant, will instruct over the phone about what to do using the American Heart Foundation resuscitation guidelines. Of course, people’s first call should be to emergency services.

Technology has a very important role to improve how heart healthcare is delivered, especially in terms of prevention through exercise, diet, life-saving treatment by Automated External Delivery, to helping manage chronic diseases that cause heart attacks, namely hypertension, diabetes, heart failure and obesity.

Medications

The standard treatment for coronary artery disease is aspirin and statins. I recommend the latter in all patients with CAD. The target for treatment is total cholesterol of 4 and LDL of 1.8.

ACE inhibitor is of benefit in terms of vascular remodelling. A good option is Trinomia, a combination pill offering all three meds in one tablet.

The remaining medications depend on symptoms of angina (beta blockers, calcium channel blockers, nitrates, potassium channel blockers, ivabradine, ranolazine) or if the patient has risk factors, such as hypertension or diabetes.

New medical options include PCSK 9 inhibitors as an alternative treatment to statins. They have less side-effects and are convenient for patients as twice-monthly injections, but they are expensive at present and only accessible to a select group of named patients. Upcoming clinical trials will show significant early cardiac event reduction with these agents.

Interventions

Drug-eluting stents are very effective treatments for the majority of patients with angiographically-significant coronary artery. Coronary artery bypass grafting (CABG) surgery is beneficial in many selected situations such as severe multi-vessel disease, especially with diabetes, in the presence of valve disease and where arteries are 100 per cent occluded; patients with smaller arteries, or complex disease, or intolerance to antiplatelet therapy, will all do better with CABG. However, with an ageing population and many with severe disease and comorbidities, CABG is not an option and complex percutaneous coronary intervention (PCI) is often required.

Future interventions may include the use of stem cell therapy to help heal damaged heart muscle; gene therapies to regress atherosclerosis or to switch off risk factors (CRISPR) and genes to predict treatment (medication, surgery, stent) success; and 3D printed stents. Telemedicine may also be able to deliver cardiac rehabilitation programmes direct to patients’ homes. Maybe a solution will emerge that can be infused to remodel the arteries and remove plaque. However, for the present time, that solution is prevention and nutrition.

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