Asymptomatic Coronary Artery Disease | What Should You Do?

Asymptomatic Coronary Artery Disease Explained

So, you’ve got asymptomatic coronary artery disease. Should you do something or nothing? Dr Malik runs through your options, breaking down the complexities in a simple way.

What is Coronary Artery Disease (CAD)?

Coronary Artery Disease (CAD) is a condition involving the coronary arteries. You have a left and right coronary artery. These are the first branches that come off the aorta, and they supply blood to your heart. Normally, they have smooth internal linings and can expand to increase blood supply during physical activities, like exercise. If you start having atherosclerosis (furring up), they can become narrow, meaning they fail to supply enough blood to the heart during exercise. 

Are there any symptoms I should be watching out for?

Angina is the most common symptom of CAD. It’s the feeling of “pain”, discomfort, breathlessness or tightness that is brought on with exercise and is a result of the heart not getting enough blood. In some patients, the heart can feel the strain, but you may not feel the pain! This is because pain is a subjective feeling. But also, the symptoms can be confused with indigestion, heartburn, being unfit, getting older… or of course, you may truly have no symptoms.

How is asymptomatic CAD screened for?

We can use several methods to screen for CAD.

• Stress test: to check for any strain on your heart.
• CT coronary angiogram: to check for any evidence of furring up – this is often the way we pick up more minor narrowings that may not cause symptoms
• Invasive angiogram: to diagnose CAD and measure the disease’s severity

Coronary Artery Disease treatment options

If you do have Coronary Artery Disease, there are several treatment options.

1. Medical therapy only

• Anti-platelets such as aspirin. There’s good evidence in younger patients, but more side effects in older patients.
• Statins to lower lipids. Statins carry a lower risk and are worth it – I am on a statin!
• Anti-anginal pills (but only if you have symptoms of angina):
  • Nitrates
  • Beta-blockers
  • Calcium channel blockers
  • Nicorandil
  • Ranolazine
  • Colchicine – an anti-inflammatory that’s now useful in treating coronary disease

2. Combining medical therapy with angioplasty & stenting

Medical therapy plus angioplasty and stenting (also known as PTCA or PCI is a less invasive option).  Angioplasty is usually done through the wrist and involves placing a stent or scaffold to open up the blockage. The latest data shows that historically, we’ve carried out too much angioplasty, so please be aware that angioplasty is only really for symptom control. Outside of having an acute heart attack, stents are unlikely to extend your lifespan.

3. Combining medical therapy with coronary bypass surgery (CABG)

If you have severe CAD, Coronary Bypass Surgery offers a “full replumbing” and may help you live longer. 

There are different types of surgeries: 

• On pump surgery vs off pump surgery
• Mini access surgery vs open chest surgery
• Full arterial revascularisation vs using a LIMA graft and veins

But you shouldn’t worry too much about the options – our private heart specialists are here to advise on the right treatment that improves your quality of life. 

How do we decide which treatment is best?

We consider the following questions:

1. Are you robust/strong enough to take the treatment offered? 
2. What does the evidence from trials, medical therapy and PCI versus CABG show? You may only need to improve your lifestyle, weight and blood pressure. 
3. What do YOU want? You may want a less invasive treatment, but if that’s significantly worse for you, we may choose not to offer that to you. Our cardiologists only advise on procedures that are going to be best for you and your quality of life.

Who finally chooses?

You’re allowed to make a bad choice – it’s your body after all. But we don’t have to carry out a certain treatment if we disagree. You may find another cardiologist who’ll do it, but that won’t change the evidence base or facts.  Real patients are harder to manage than trial patients. The Multidisciplinary team (MDT) is useful when a plan is not clear-cut – but in the end, you and your own doctor have to agree on a plan!

 

Watch Dr Malik delivering a talk to Cardiothoracic surgical trainees and running through the evidence – should you do something, or nothing? 

Book your consultation

If you have asymptomatic Coronary Artery Disease and are struggling to decide what to do, please book a consultation, I will be more than happy to see you. Let’s get the quality of your life back.

Article by Dr Malik, a UK leading cardiologist. He works at One Welbeck Heart Health – London’s Largest Private Cardiology Group, and at Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, one of the largest NHS Trusts in the UK.