Appropriate Criteria for coronary revascularization

1. Appropriate Criteria for coronary revascularization The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, conducted an update of the appropriate use criteria (AUC) for coronary revascularization. In general, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of AUC is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

2. Introduction to Presentation  This presentation is prepared to explain the basics of treatment of coronary heart disease. The treatment consists of life style changes, medications and revascularisation procedures, like angioplasty or bypass surgery. The presentation tries to explain in general what type of patients need angioplasty or bypass surgery. The purpose of this presentation is to clarify the basics so that the patients have opportunity to get second opinion of a senior cardiologist. Universal Healing Program (UHP) launched on October 2, 1991 empowers the patient to make life style changes and enables him to deal with stressful situations with equanimity. UHP can be downloaded free from our website: Universalhealing.org

3. Management of Coronary Heart Disease Dr. Ramesh I. Kapadia MRCP ( Cardiology) FRCP (Edin.) Director, Universal Healing Program www: universalhealing.org E Mail:rameshkapadia34@gmail.com

4. Basics of Coronary Heart Disease Coronary heart disease results due to lack of blood supply to the heart muscle. Coronary arteries supply blood to heart muscle. They become narrow due to fat like deposition in their walls.

5. Variable factors However, the walls of arteries are also very sensitive and they go into spasm due to a variety of reasons leading to narrowing of the artery, e.g. cold weather and stressful situations. The circulating blood can become thicker in consistency for similar reasons. So there is the fixed element due to deposition of fat like material and variable element of spasm and varying consistency or thickness of circulating blood.

6. Further, the heart muscle requires rest when blood supply is curtailed following a sudden occlusion due to a blood clot. We cannot give complete rest to heart muscle as we give rest to other parts of the body. Heart has to function ceaselessly to keep the body alive. Occlusion by a Clot So the physical as well as nonphysical, call it spiritual, measures are required to manage coronary heart disease. The book,Heal Your Heart: Heart Disease, Prevention and Total Healing, tries to explain this combined perspective in total healing of coronary heart disease.

7. Reassurance by a physician is the Key Factor in successful management of coronary heart disease Cure of an illness determined by 3 tenets Tenet 1: Doctor's faith in himself Tenet 2 : Patient's faith in the doctor Tenet 3 : The doctor's KARMA(his skill and its application with love) This advice confirms the first of the 3 tenets of Tibetan medicine enunciated by Dalai Lama to Harvard Professor Dr. Benson John who went to Dharamshala to study the benefits of meditation. H.H.Dalai Lama Dr. Benson John

8. Stable Angina: Stable exertional symptoms In any study, coronary revascularization using angioplasty or bypass surgery has not shown advantage in saving life when used in patients with stable angina. From Toothache To Nausea Typical presentation of angina Atypical presentation of angina

9. Heart attack Unstable symptoms or rest angina Angioplasty is shown to save life only in patients of unstable angina or patients actually having heart attack.

10. Management of Stable Coronary Disease On the contrary, the randomized trials have demonstrated that nitrates, aspirin, beta-blockers, calcium-blockers, angiotensin converting enzyme (ACE) inhibitors, lipid lowering medications and life style changes can save lives in patients with stable coronary heart disease. Current consensus is that angiography should be reserved for patients where surgery or angioplasty is considered necessary. If angiography is done before that decision, just to “look”, there is a risk of the patient being scared that he is sitting on a ‘volcano’ which may kill him at any time. This may not be true.

11. Unnecessary Interventions There is a well described phenomenon called “occlulostenotic reflex” where a mere stenoses without symptoms or clear indication for treatment, ends up with stent or surgery because doctors and patients cannot reconcile with the fact that all stenoses do not require treatment.

12. Bypass Surgery For a large number of patients undergoing bypass surgery there is no evidence that it improves their survival compared to those managed by medical means. Bypass surgery only improves survival in patients with the left main artery disease or three vessel disease with impaired left ventricular function but does not offer survival benefit when the left ventricular function is good.

13. Quality of Life Improvement • Bypass surgery or angioplasty can help to eliminate angina which improves quality of life for active individuals • This is an important consideration for revascularization even in stable patients who as we know are not at risk of dying or having a heart attack

14. Natural Healing Patients with stable angina have very low annual mortality of approximately 1%, which is not significantly higher than that of the general population. When the plaque grows in the wall of the coronary artery, coronary arteries are capable of remodeling themselves and enlarging at the site of plaque formation. Many times small blood vessels (collaterals) grow around the blockages to provide additional routes for blood flow. This reminds us of our father of medicine, Hippocrates’s observation that the body has inherent capacity to heal itself.

15. What is necessary? In the management of coronary heart disease the approach varies from doctor to doctor and from patient to patient. It depends not only on the severity of the disease but also on the perception of the severity by the attending doctor. Every case has to be evaluated on its own merit from all perspectives. Stress echo-cardiography and stress nuclear scan are also at times advised to assess the need for angiography and also to determine how much benefit a patient would derive from revascularization procedure.

16. Need for Alternative Measures The patients, even with advanced coronary heart disease, especially those who are considered technically unfit for surgical intervention, are also benefited by intensive medical management, lifestyle changes and in-depth stress management. There are a large number of patients who cannot afford surgery. They also now have a ray of hope in successful management of their problem. This involves the patient's participation in in-depth stress management consisting of abdominal breathing, shavasana, meditation, visual imagery and group discussion with emphasis on sharing of feeling along with intensive medical management.

17. These observations are based on the results of the Universal Healing Program conducted at Ahmedabad, India, since 2, October 1991.

18. Universal Healing Program (UHP) isIntegral Management of coronary heart disease. • Conventional management: medication, lifestyle changes and intervention when necessary. • The integral management implies addition of in-depth stress management to increase spiritual strength (ISMSS) , that is practice of universal healing program. • Integral management has two distinct advantages. • It empowers the participants to make life style changes. • It helps to overcome the fear of the disease. • UHP: • Diet Counseling. • Moderate exercise like walking daily for 30 to 40 minutes. • Stretching and relaxation exercises leading to progressive deep relaxation, i.e. Shavasana. • Meditation and Visual Imagery. • Group discussion with emphasis on sharing of feeling.