• Home
  • Aim of this blog

Dr.S.Venkatesan MD

Expressions in cardiology

Feeds:
Posts
Comments
« CAD management in cross roads : Ischemia vs Ignorance driven PCI ?
Why ventricular tachycardia has wide QRS complex ? »

How common is the progression of non-culprit lesion after PTCA ? What is the significance?

November 24, 2019 by dr s venkatesan

Whenever a patient is getting discharged after a PCI, the treating cardiologist often faces this situation.

So, you fixed the block in my coronary artery doctor. Thank you so much. Now, I can have a peaceful life, free from  future heart problems. “Am I right doctor”?

I wish I can answer “Yes”  to your query but I can’t for the following reasons.

I have fixed only a lesion that caused maximum obstruction. Atherosclerosis is a diffuse disease and you have minor plaques scattered across your coronary artery. These can grow at its own will. So you carry a definite risk remote from the current problem. (Don’t get frightened, read further, you have definite solutions to reduce this risk.)

How common is the progression of native vessel disease?

It varies from 10 to 40%. Mind you, the exact incidence directly depends upon the compliance of medical management, risk factor reduction, and adaptation to a new life healthy lifestyle. In effect, you (the patients) decide the incidence.

One surprise phenomenon (though unproven) might happen. Since the tightest lesion is jailed with a scaffold the minor lesion is preselected to an accelerated process of atherosclerosis if medical treatment is not properly followed.

Dr.Zellweger from the university hospital, Basel, did an extraordinary study with 400 patients, meticulous 5 years follow up with SPECT and found remote lesions accounted for 40% of future events (Basel Stent Kosten-Effektivitäts Trial [BASKET]) The other study by Glazer and concurred with this. These studies reiterate the importance of taking care of the entire coronary artery instead of focused piecemeal care by scaffolds.

Does a proximal DES protect a  distal lesion in the same artery by the drug effect?

It is a good thing to happen at least on paper. A proximal LAD with the latest generation Everolimus coated stent is expected to keep the distal LAD drugged for few months at leas.( with anti-mitotic activity) Thus preventing the progression of distal lesions.

No, I can’t believe this.In this era of momentary touch on sidewalls of artery by drug-eluting balloon (DEB) shown to do wonders, anything is feasible. Chacko’s (Ref 2 : JACC CV Interventions 2009)observation has a possible answer for this. It showed BMS vs DES didn’t make any difference in remote lesion progression.

Final message 

These studies reaffirm one vital truth. Stents are temporary solutions to a permanent, systemic disease of the vascular system .Stents are indeed a major revolution in CAD, “if and only if” it’s used in a highly selected CAD population. Global attempts to project cath labs as a tool to control human atherosclerosis is a typical example of flawed science. The only effective way to tackle this menace is to faithfully follow overall healthy living,  assisted by drugs.

This is the Editorial in response to Zellweger’s article

 

Reference

1.Glaser R, Selzer F, Faxon DP,Clinical progression of incidental, asymptomatic lesions discovered during culprit vessel coronary intervention.Circulation. 2005 Jan 18;111(2):143-9 2004 Dec 27
2.
3.

Postamble

One of my patients asked some time ago. If stents are the definite remedy for severe arterial narrowing, why not stent all my lesions (even the minor ones ) prophylactically doctor, so that it will not become tight at a later date?

That’s a good query. Your doubt is genuine , appear logical as well. But, unfortunately, it will be the most dangerous thing to do*. Metals are never friendly with the coronary arterial wall. We should use it extremely judiciously and only with tight flow-limiting lesions. These metals require annual (rather permanent) maintenance. Its taken care by multiple antiplatelet drugs. If for some reason your maintenance is erratic or the drugs fail to act you are at more risk of a future event.

(* This is what has  happened (happening) in the past, that demanded urgent publication of appropriate usage criteria)

Now, the current belief among the “fair thinking cardiology community” is dramatically changing. It’s leaning towards non-stent management even with significant flow-limiting obstructions in otherwise stable patients(SIHD). This belief is accruing more and more evidence base (The COURAGE 15 year follow up / ORBITA/ISCHEMIA)   All these studies confirm the emerging doctrine and bring back some semblance of sense into the cardiology community.

Rate this:

Share this:

  • LinkedIn
  • WhatsApp
  • Twitter
  • Facebook
  • Email

Related

Posted in Uncategorized | Tagged COURAGE ORBITA ISCHEMIA, post ptca care, progression of native vessel disease after ptca |

  • Categories

  • Archives

    • February 2021 (6)
    • January 2021 (8)
    • December 2020 (4)
    • November 2020 (5)
    • October 2020 (7)
    • September 2020 (7)
    • August 2020 (10)
    • July 2020 (6)
    • June 2020 (9)
    • May 2020 (9)
    • April 2020 (5)
    • March 2020 (7)
    • February 2020 (3)
    • January 2020 (4)
    • December 2019 (4)
    • November 2019 (6)
    • October 2019 (3)
    • September 2019 (6)
    • August 2019 (3)
    • July 2019 (1)
    • June 2019 (3)
    • May 2019 (2)
    • April 2019 (2)
    • March 2019 (2)
    • February 2019 (4)
    • January 2019 (2)
    • December 2018 (2)
    • November 2018 (2)
    • October 2018 (2)
    • September 2018 (1)
    • August 2018 (2)
    • July 2018 (3)
    • June 2018 (1)
    • May 2018 (3)
    • April 2018 (1)
    • March 2018 (3)
    • February 2018 (3)
    • January 2018 (1)
    • December 2017 (3)
    • November 2017 (3)
    • October 2017 (3)
    • September 2017 (2)
    • August 2017 (2)
    • July 2017 (2)
    • June 2017 (2)
    • May 2017 (4)
    • April 2017 (3)
    • March 2017 (3)
    • February 2017 (5)
    • January 2017 (3)
    • December 2016 (2)
    • November 2016 (5)
    • October 2016 (4)
    • September 2016 (3)
    • August 2016 (5)
    • July 2016 (3)
    • June 2016 (4)
    • May 2016 (3)
    • April 2016 (6)
    • March 2016 (4)
    • February 2016 (3)
    • January 2016 (5)
    • December 2015 (6)
    • November 2015 (5)
    • October 2015 (8)
    • September 2015 (2)
    • August 2015 (5)
    • July 2015 (7)
    • June 2015 (4)
    • May 2015 (6)
    • April 2015 (5)
    • March 2015 (7)
    • February 2015 (15)
    • January 2015 (8)
    • December 2014 (5)
    • November 2014 (8)
    • October 2014 (7)
    • September 2014 (9)
    • August 2014 (5)
    • July 2014 (11)
    • June 2014 (5)
    • May 2014 (4)
    • April 2014 (5)
    • March 2014 (8)
    • February 2014 (8)
    • January 2014 (5)
    • December 2013 (7)
    • November 2013 (7)
    • October 2013 (14)
    • September 2013 (11)
    • August 2013 (15)
    • July 2013 (15)
    • June 2013 (15)
    • May 2013 (15)
    • April 2013 (15)
    • March 2013 (15)
    • February 2013 (15)
    • January 2013 (15)
    • December 2012 (15)
    • November 2012 (15)
    • October 2012 (15)
    • September 2012 (15)
    • August 2012 (15)
    • July 2012 (15)
    • June 2012 (15)
    • May 2012 (15)
    • April 2012 (15)
    • March 2012 (15)
    • February 2012 (15)
    • January 2012 (15)
    • December 2011 (15)
    • November 2011 (17)
    • October 2011 (17)
    • September 2011 (17)
    • August 2011 (21)
    • July 2011 (20)
    • June 2011 (17)
    • May 2011 (15)
    • April 2011 (17)
    • March 2011 (25)
    • February 2011 (20)
    • January 2011 (20)
    • December 2010 (18)
    • November 2010 (21)
    • October 2010 (21)
    • September 2010 (25)
    • August 2010 (20)
    • July 2010 (10)
    • June 2010 (11)
    • May 2010 (19)
    • April 2010 (16)
    • March 2010 (14)
    • February 2010 (22)
    • January 2010 (18)
    • December 2009 (20)
    • November 2009 (20)
    • October 2009 (3)
    • September 2009 (21)
    • August 2009 (19)
    • July 2009 (12)
    • June 2009 (12)
    • May 2009 (11)
    • April 2009 (15)
    • March 2009 (21)
    • February 2009 (4)
    • January 2009 (12)
    • December 2008 (13)
    • November 2008 (9)
    • October 2008 (22)
    • September 2008 (20)
    • August 2008 (16)
    • July 2008 (14)
    • June 2008 (7)
  • Blog Stats

    • 5,362,186 hits
  • Please give your feed back .

  • Click below to see who is watching this website live !

  • This site will never aim for profit. Still ,this donation link is added at the request of few visitors who wanted to contribute and of-course that will help make it sustainable . Donate Button with Credit Cards
  • Please Note

    The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.

WPThemes.


Cancel

 
Loading Comments...
Comment
    ×
    loading Cancel
    Post was not sent - check your email addresses!
    Email check failed, please try again
    Sorry, your blog cannot share posts by email.