How a wire in your wrist can help you avoid surgery for blocked arteries
00:52 GMT, 18 December 2012
00:52 GMT, 18 December 2012
Every year in England alone, 61,000 people are given a stent — a tiny metal tube — to open up their narrowed heart arteries.
There can be complications as a result of this surgery — Ian Lawrence, 43, an Army cadet instructor from West Dulwich, London, underwent a new procedure in May last year to assess the need for stenting.
'Out of the blue I had a heart attack,' said Ian Lawrence
Until last year I’d never had a health issue at all — but then out of the blue I had a heart attack.
I was walking up the hill to my house when both my arms went numb.
I saw my GP the next day, who said to call her immediately if it happened again.
Then on the way back from the surgery the numbness came back in both arms, and I also felt a dull ache below my shoulder blades.
I called an ambulance, which took me to King’s College Hospital, London.
After tests, the doctors confirmed I’d had a heart attack.
The numb feeling I’d had the day before had probably been one, too.
It obviously shocked me — I’m stocky, but not overweight.
I do smoke about 20 cigarettes a day, but I’m fit because of working with the Army and I run.
But two of my mum’s sisters have had heart surgery and her nephew had one at 35, which he survived, so maybe it runs in the family.
I was kept in overnight, and the next day I was told the heart attack was probably due to narrowing of my arteries.
The cardiologist Dr Philip MacCarthy explained the usual treatment is to insert a small metal tube called a stent into the artery to keep it open — they put it in through an incision in the wrist and thread it up to the narrowed artery to keep it open.
But Dr MacCarthy said it was best to avoid giving a stent if possible because there’s a risk it may lead to the artery narrowing again or trigger a blood clot.
Stents should be used only when the narrowing is actually slowing down the blood flow — the problem is that you can’t always see this clearly with the usual X-ray of blood vessels.
However, Dr MacCarthy said there was a new, more accurate method to look at the blocked artery; they’d insert a wire to measure the blood pressure, so they’d definitely know if I really needed a stent or not.
'I had a stent fitted in my right artery under a local anaesthetic and sedative,' said Ian
The next afternoon I had the pressure wire inserted into my artery via my wrist under local anaesthetic.
Dr MacCarthy said it showed I did need a stent after all as there was a significant narrowing in my right main coronary artery and the blood wasn’t flowing through it sufficiently.
That was definitely worrying: my
partner Karen, stepdaughter Abbie, 15, and son Bradley, who’s also 15,
were obviously worried, too.
So that day I had a stent fitted in my right artery under a local anaesthetic and sedative.
I felt fine afterwards and was allowed home the next day.
July, a couple of months after the operation, further checks revealed I
still had some narrowings, and after more tests with the pressure wire,
Dr MacCarthy said I needed two stents in my left coronary artery, too.
time I felt some bruising in my chest afterwards and I had to take it
slowly for a month when walking up hill or I’d get breathless.
But in September I was back at work, on restricted duty only as there’s usually lots of physical activity in my work.
I feel absolutely fine with no aches or breathlessness, and tests show
all’s fine with my heart, so I hope any day now to be allowed back on
I do have to take eight pills a day, such as one to regulate my heartbeat and aspirin to thin my blood.
I hope in time I can cut these down. I’ve started eating more healthily, and I did give up smoking for a year, but have just started again. I will try to stop again — I’m very grateful that I received such great help.
Dr Philip MacCarthy, consultant cardiologist at King’s College Hospital, London. He says:
Coronary artery disease is the UK’s biggest killer — with one in five men and one in seven women dying from it.
This is often caused by the arteries becoming blocked with cholesterol and other fatty substances, which stops blood flowing to the heart.
The main method for treating those at risk is a coronary angioplasty, where a short wire-mesh tube, called a stent, is inserted through the wrist into the artery in the heart to allow blood to flow more freely through it.
More than 61,000 angioplasty procedures are performed in England each year. Most are successful, but serious complications can occur.
These include bleeding after the operation, occurring in one in 200 cases; a heart attack, which occurs in one in 400 cases because the stent can block little branches of the artery; and a stroke, which happens in one in 600 cases. In one in 1,000 cases, the patient dies.
Once the stent is in, there’s a small risk of longer-term complications, such as blood clots forming in the stent or re-narrowing of the stent caused by scarring, which can require a further procedure.
Coronary artery disease is the UK's biggest killer – with one in five men and one in seven women dying from it
A new generation of stents that are coated in drugs have reduced this dramatically, but it does still occur.
Stenting is not especially risky — however, the thinking is it’s better not to take the small risk and expense if the stent is not needed.
We think a significant proportion — around 20 per cent — of coronary stent procedures carried out may not have been necessary and medication such as beta-blockers, aspirin and statins would have been a better treatment.
The problem is cardiologists cannot always tell from the angiogram — an X-ray of the arteries — whether a stent is absolutely necessary.
The angiogram gives a picture of the narrowing, but tells us little about what is happening to the blood flowing down the artery.
Some narrowings don’t actually need stenting because the blood flow is not significantly limited — and sometimes the narrowings don’t look too severe on the angiogram when, in fact, they are affecting blood flow.
The pressure wire is an altogether better way of assessing the need for a stent.
The wire has a tiny, extremely accurate sensor in its tip that precisely measures blood flow and blood pressure in the artery. By measuring pressure in this way we can improve the patient’s outcome, while also saving costs.
We’ve even had cases using the pressure wire in which a narrowing has been shown not to be affecting blood flow at all, and no treatment was needed.
The pressure wire costs 330 for each one — they are disposable — which is about the same as a stent.
Although the wires were developed in Belgium and Holland in the late Nineties and I first tried one a decade ago, there were no studies until very recently to back up the manufacturer’s claims that this was a more accurate method.
In a 2009 study involving 1,000 patients in the U.S. and Europe, patients who underwent an angiogram with the additional pressure wire technique received a third fewer stents than those examined only with an angiogram.
After one year, within the traditional group, 18.4 per cent of the patients had died, suffered a heart attack or needed bypass surgery or a repeat stent procedure, compared with 13.2 per cent among those who received the pressure wire test.
Then the FAME II study was published in August in the New England Journal of Medicine. It was carried out by myself and other cardiologists and involved 1,220 patients.
The study was halted early because the results were so conclusive — patients had an 86 per cent lower risk of returning to hospital for urgent treatment when pressure wires were used.
Our new findings provide conclusive proof for the first time that this technology is beneficial to patients, and helps us decide the best treatment to offer.
It’s very exciting and could ultimately save lives.
Unfortunately, many cardiologists here and abroad still don’t use it yet and rely on the angiogram, partly because of lack of awareness.
I hope this changes in the next year.
Most NHS hospitals can carry out pressure wire assessment, but not all cardiologists do it. It is also available privately — the artery study alone using a pressure wire (without any treatment) costs 2,000-3,000.