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Frequently Asked Questions - General faq's
Most common answers to your common questions
Angina pectoris, commonly known as angina, is chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart's blood vessels). Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries. The term derives from the Greek ankhon ("strangling") and the Latin pectus ("chest"), and can therefore be translated as "a strangling feeling in the chest".
Most patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck, jaw, or shoulders. Typical locations for radiation of pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating and nausea in some cases. It usually lasts for about 1 to 5 minutes, and is relieved by rest or specific anti-angina medication. Chest pain lasting only a few seconds is normally not angina.
The coronary arteries are small arteries that carry blood to the heart muscle. This blood flow provides the oxygen and nutrients needed by the heart itself so that it can keep pumping. If the heart has to speed up (for example, during exercise or periods of excitement) and cannot get the blood it needs, it will send out a signal in the form of angina.
The three major coronary arteries are the:
- Left anterior descending artery
- Left circumflex artery
- Right coronary artery
Most people with angina have blockages in one or more of these arteries and/or their branches. A cardiologist (heart specialist) will perform various tests to determine the location and extent of the blockage.
In almost all cases, the underlying cause of angina is the critical narrowing of one or more of the coronary arteries that supply blood to the heart.
Coronary artery disease - also known as coronary heart disease (CHD) or ischemic heart disease (IHD) - affects most people as they age. The coronary arteries become constricted or blocked by atheromas - bulging masses or "plaques" that form within the walls lining the arteries.
The exact cause(s) of coronary artery disease remains unknown. Yet experts have identified some of the risk factors that increase a person's chance of getting this disease. They include:
- Aging
- High blood pressure (hypertension)
- Cigarette smoking
- High blood cholesterol
- Being overweight
- Lack of exercise
- Family history of angina or heart attack at a young age
- Diabetes
Certain individuals, though, develop angina without having any of the above common risk factors for CAD.
Angina episodes often occur when narrowed or blocked coronary arteries are unable to supply enough blood to the heart muscle. It adversely restricts people from normal daily activities
· Person is able to walk but unable to do running or walking uphill.
· Carrying heavy packages.
· Climbing stairs.
· Mowing the lawn.
· Playing sports.
· Sexual Intercourse may become difficult – or impossible.
That can be deeply depressing, especially for people for whom physically activity and independence have been important. Even beyond that, a diagnosis of heart disease can be emotionally devastating. First comes a flurry of medical testing, which is stressful to schedule and undergo. Medication may be prescribed, and the doctor may suggest some major lifestyle changes in diet or exercise that may be stressful or bothersome to implement. . As a result, many people experience fear, anxiety, and difficulty sleeping after being diagnosed with angina.
Doctors recommend controlling the risk factors that contribute to the underlying coronary artery disease. These risk factors include high blood pressure, diabetes, cigarette smoking, high blood cholesterol levels, and excess weight.
Angina is usually controlled by one or more medications that either increase the supply of oxygen to the deprived heart muscle by dilating coronary vessels, or decrease the heart's demand for oxygen by slowing the heart rate, decreasing intensity of contraction or reducing stress within the walls of the hearts chambers. Unfortunately, in most patients, medication becomes insufficiently effective over time.
Bypass surgery or angioplasty is usually recommended if medication fails to ease angina or if the risk of heart attack is high. For some patients, IECP® treatment is another option that may relieve or eliminate angina by improving oxygen delivery to the heart muscle.
The acronym IECP stands for Increased External Counterpulsation.
IECP® or Increased External Counterpulsation treatment is a non-surgical, non-pharmaceutical, treatment for heart disease that is used to relieve or eliminate angina. During the treatment, blood pressure cuffs are wrapped around your legs, and squeezed and released in sync with your heartbeat, promoting blood flow throughout your body and particularly to your heart. In the process, IECP develops new pathways around blocked arteries in the heart by expanding networks of tiny blood vessels ("collaterals") that help increase and normalize blood flow to the heart muscle. For this reason, it is often called the NATURAL BYPASS.
Unlike procedures such as bypass surgery and balloon angioplasty, IECP® treatment carries very little or no risk and is very comfortable. Increased External Counterpulsation is an option for patients' who are unsuitable for invasive procedures or unwilling to undergo them. For patients who have undergone multiple invasive procedures and for whom addition surgery carries excessive risk, Increased External Counterpulsation may be the only way to obtain relief form crippling angina.
Patients lie on a padded table in a treatment room as shown in the adjoining picture. Three electrodes are applied to the chest to record a constant ECG reading. A finger sensor, called a plethysmograph, records a tracing that represents blood pressure. A set of cuffs is wrapped around the calves, thighs, buttocks and arms. The system uses an ECG signal to electronically synchronise inflation and deflation of the cuffs. Patients experience a sensation of a strong "hug" moving upwards from the calves to thighs to buttocks during inflation followed the rapid relief of pressure on deflation. During IECP® treatment, a display shows an ECG signal and a blood pressure tracing. An IECP® therapist uses these readings to time Counterpulsation and monitor treatment.
Ask your physician to evaluate you. You may be a candidate for IECP® if you:
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Have chronic stable angina.
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Are not receiving adequate relief from angina by taking nitrates.
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Do not qualify as a candidate for invasive procedures.
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Have exhausted invasive treatments without lasting relief of symptoms.
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Are unwilling to undergo surgery or angioplasty.
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Want to explore alternatives to bypass surgery or angioplasty.
Normal heart function depends on maintaining a balance between oxygen supply and demand. Oxygen consumption by the cardiac muscle is determined by how fast your heart is beating and how well it pumps. The amount of oxygen available is determined by blood flow. Approximately 80 percent of the blood flow to the cardiac muscle tissue occurs when the heart is resting.
Clinical studies indicate that IECP® treatment may create a "natural" bypass of blocked arteries. IECP® treatment encourages blood vessels to open or form small channels that become extra branches. These channels, or collaterals, may eventually become permanent pathways to the heart muscle that was previously deprived of blood flow and adequate oxygen.
Clinical studies indicate that IECP® treatment may create a "natural" bypass of blocked arteries. IECP® treatment encourages blood vessels to open or form small channels that become extra branches. These channels, or collaterals, may eventually become permanent pathways to the heart muscle that was previously deprived of blood flow and adequate oxygen.
The length of treatment may be a consideration for some people. It can take between four and seven weeks to complete a course of IECP® treatment. During that time, patients must visit an outpatient clinic and receive treatment for one to two hours per day. Some patients may require more than one course of therapy to achieve an optimal level of relief.
IECP is safe. Occasionally, some patients experience mild skin irritation under the areas of the blood pressure cuffs. The IECP therapists can cope up with this irritation by using extra padding to make the patient comfortable. Some patients experience a bit more fatigue at the beginning of their course of treatment, but it usually subsides after the first few sessions. In fact, patients typically feel energized by IECP.
· Patient can walk more distance without chest pain
· Patient would have fewer or no angina
· Episodes of angina would be less painful
· Patient can return to work and can participate in their active life style once again
· Patient would be more energetic and confidence.
You are encouraged to go for your IECP treatment every day. However, missing a day will not have a negative effect on your overall results. When you come back, you will simply pick up where you left off, and the missed treatment will be added to the end of your program until you have a total of 35 sessions. Just like exercise, the more consistent you are with your IECP schedule, the better your results will be.
No. Our bodies obey the laws of physics, and one principle law is that fluid will follow the path of least resistance. Atherosclerotic plaques are calcified and hard, and they create an obstruction that detours the blood through alternate routes. During IECP, when your blood is flowing to your heart, it will naturally bypass arteries with plaque and enter healthy, non-diseased around the blockages is a longer trip, but it is a much easier one. In time, these new pathways are reinforced and become lasting routes for blood to reach your heart beyond the blockages. Every IECP patient has had multiple, serious blockages. No one has ever had a heart attack or a stroke as a result of the treatment.
Yes. If you have hypertension that is properly managed, you may undergo IECP without difficulty. Oftentimes, patients with hypertension find that their blood pressure improves as they proceed with IECP. If your hypertension is uncontrolled, you must seek medical care to get your blood pressure under control with proper medications before proceeding with IECP.
Yes, and you should! IECP improves blood flow throughout the entire body, including your legs. If you have poor leg circulation, you might need more than 35 treatments. My patients typically require at least 50 treatments to get the full benefit of the program. In addition to improved stamina, fewer anginas, and less nitro-glycerine use, patients with PVD have a marked improvement in their leg circulation in response to IECP.
Yes. Varicose veins are typically a cosmetic issue, not a medical one. As such, they do not prevent individuals from receiving IECP. An IECP therapist can use extra padding in patients with varicose veins to ensure maximum comfort.
Yes. Having a history of a blood clot (deep venous thrombosis or DVT) in your leg does not prohibit you from having IECP. It is recommended that you have Doppler ultrasound of your leg to confirm the blood clot has resolved before beginning the IECP program.
No. In fact, in July 2002 the FDA approved IECP as a treatment for congestive heart failure (CHF). After completion a course of IECP treatment, Patients with CHF typically have less swelling in their legs, less shortness of breath, less fatigue, and often require less diuretic medication.
No. World over hospitals have successfully treated patients as young as 36 and as old as 97 without any difficulties. Many of patients are in their 80s and complete the entire IECP program with excellent results.
Yes! Most of the patients undergoing IECP are those who have already had one (or many) of these procedures. They are recommended IECP treatment because they still have angina.
All these current mode of treatments help the heart by increasing the blood flow to the area of the heart muscle not receiving adequate blood supply. Once the blood supply is increased towards normal the patient's chest pain will be decreased or eliminated and his exercise tolerance will improve. During IECP hearts natural mechanism of forming new vessel is increased which markedly increase the blood supply to the heart muscle. IECP also tends to improve your endothelial cell function that lines your coronary arteries, which determine your chance of getting heart attacks.
Not necessarily but some patients who want to compare the post IECP treatment improvement with their previous reports. They can repeat their Exercise treadmill test or Echo cardiography or nuclear scan after the treatment. Some physician might feel follow-up test is unnecessary since the patient symptomatic clinical improvement itself has demonstrated increase blood flow to the heart muscle.
IECP is a safe, outpatient, non-invasive treatment. So you don't have to restrict any of your daily routine work. You can fix your one-hour time treatment schedule according to your convenience. Before you start the treatment you will be asked to wear tight fitting elastic pant. This is to prevent skin irritation and abrasion.
Clinical studies have shown that IECP® is an effective treatment for angina. A randomised, controlled, blind study showed a significant increase in the length of time that participants who received active treatment were able to exercise. Additionally, participants who received active treatment experienced fewer episodes of angina. Studies have demonstrated benefits including:
- Elimination or decrease in exercise-induced signs of lack of oxygen to the heart muscle (ischemia).
- Increased exercise tolerance
- Elimination or decrease in episodes of angina
- Decrease in need for anti-anginal medication
- Patients can walk further, carry heavier packages, and be more active without having angina.
- Patients have fewer episodes of angina.
- Episodes of angina are less painful.
- Patients need less anti-anginal medication.
- Patients can return to work, go out to dinner, garden, travel or enjoy golf, tennis, or bowling once again.
- Patients feel more confident about participating in their social lives, volunteer activities, and exercise without interference from angina
The body has its own solution to an inadequate blood supply caused by blocked or partially blocked arteries. When an artery is severely narrowed, the body can increase the amount of blood flowing to the heart muscle by opening up small branches of nearby arteries. Known as collateral circulation, these networks of blood vessels create new routes for blood to detour around clogged arteries.
The development of a collateral circulation is particularly important in the heart muscle where it may be life saving. However, the development of collateral circulation is a gradual process, and not everyone has the same ability to develop these networks. In a three year, follow-up study, the majority of patients remained free of angina and showed persistent improvements in their thallium scans
Some patients have experienced minor skin irritation due to the pressure of the cuffs. You should consult with your physician regarding any risk and complication factors.
Unlike procedures such as bypass surgery and balloon angioplasty, IECP® treatment is administered in outpatient sessions, carries little or no risk, and is relatively comfortable.
Some patients with more extensive disease or who have disease of the left main coronary artery may require bypass surgery. IECP® treatment is an option for patients who are unsuitable for invasive procedures or unwilling to undergo them. For patients who have undergone multiple invasive procedures and for whom additional surgery carries excessive risk, IECP® therapy may be the only way to obtain relief from crippling angina.
Some patients with more extensive disease or who have disease of the left main coronary artery may require bypass surgery. IECP® treatment is an option for patients who are unsuitable for invasive procedures or unwilling to undergo them. For patients who have undergone multiple invasive procedures and for whom additional surgery carries excessive risk, IECP® therapy may be the only way to obtain relief from crippling angina.
Patients typically attend one-hour treatment sessions once a day, five days a week, for seven weeks. Many people have continued their employment while receiving treatment by scheduling their sessions before or after work. Patients with extensive atherosclerotic disease may require more than 35 hours of treatment to achieve optimal benefit.
In 1989, researchers at State University of New York at Stony Brook began clinical studies of ECP treatment. Until the summer of 1995, ECP therapy was only available to patients participating in clinical studies. Today, ECP therapy is available at treatment centres throughout the world.
A recent study “The prospective evaluation of IECP in Heart Failure (PEECH) Trial” showed that IECP can benefit patients with stable heart failure (HF) and Left Ventricular Dysfunction (LVD).
Angiograms are used to evaluate the condition of the coronary arteries and nourishment of the heart muscle. A dye which can be imaged by x-ray techniques is injected into the heart's blood vessels via a catheter, providing a recordable view of blood as it courses through the heart's arteries.
Percutaneous Transluminal Coronary Angioplasty (PTCA) is an invasive procedure that involves inserting a slim hollow tube through a major artery and into a blocked vessel. A small balloon at the tip of the catheter is inflated alongside the obstructing plaque deposits, flattening them against the vessel wall to restore blood flow. No anaesthesia is necessary. The patient often can go home the same day.
When the heart contracts during its pumping phase (systole), the coronary vasculature is squeezed by the powerful contraction of heart muscle, limiting the flow of blood to and within the muscle (myocardium). The myocardium must therefore receive most of its oxygenated blood during its period of relaxation (diastole), when large coronary arteries are most receptive to blood flow. Muscles, especially the large weight-bearing ones of the lower body, contain large numbers of blood vessels that cumulatively hold a large volume of blood. During IECP® treatment, at the onset of each diastole, compressive air cuffs that surround the muscles of the lower body are quickly inflated in rapid succession, first at the calves, then at the lower thighs, then at the upper thighs and buttocks. The rapid and precisely timed "squeezing" of the muscles sends a wave of blood (and pressure) that travels toward the heart through both veins and arteries. The sequential compression ensures that the waves generated in the more distant calf muscles can pass under the next cuffs (lower thighs) and be reinforced (not trapped) by the second and third compressions of the sequence. The result of the combined compressions is an increase in venous return (delivery of deoxygenated blood to the right atrium), and an "augmentation" or enhancement of diastolic pressure, which improves myocardial perfusion (flow of blood through the coronary arteries and to the heart muscle.
The amount of blood pumped out of the heart (cardiac output), the tone of the walls of the arteries (vascular resistance), and the volume and viscosity of the blood influence the pressure (expressed in millimetres of mercury) of the blood against the walls of the arteries. Each blood pressure measurement has two numbers. The first or top number is systolic blood pressure (pressure within the arteries during systole, when the heart is contracting). The second or bottom number is diastolic pressure (pressure within the arteries when the heart is relaxing). Normally, systolic pressure is the higher number. During IECP treatment sessions, diastolic pressure is increased and systolic pressure is decreased, usually to a degree that diastolic pressure exceeds systolic pressure.
When the heart contracts during its pumping phase (systole), the coronary vasculature is squeezed by the powerful contraction of heart muscle, limiting the flow of blood to and within the muscle (myocardium). The myocardium must therefore receive most of its oxygenated blood during its period of relaxation (diastole), when large coronary arteries are most receptive to blood flow. Muscles, especially the large weight-bearing ones of the lower body, contain large numbers of blood vessels that cumulatively hold a large volume of blood. During IECP treatment, at the onset of each diastole, compressive air cuffs that surround the muscles of the lower body are quickly inflated in rapid succession, first at the calves, then at the lower thighs, then at the upper thighs and buttocks. The rapid and precisely timed "squeezing" of the muscles sends a wave of blood (and pressure) that travels toward the heart through both veins and arteries. The sequential compression ensures that the waves generated in the more distant calf muscles can pass under the next cuffs (lower thighs) and be reinforced (not trapped) by the second and third compressions of the sequence. The result of the combined compressions is an increase in venous return (delivery of deoxygenated blood to the right atrium), and an "augmentation" or enhancement of diastolic pressure, which improves myocardial perfusion (flow of blood through the coronary arteries and to the heart muscle.
The cardiac cycle is the period from the beginning of one heartbeat to the beginning of the next. The cardiac cycle includes diastole when the heart relaxes and fills with blood, and systole when the heart contracts and pumps blood out of the body.
When a blockage (stenosis) within an artery prevents that vessel from delivering an adequate supply of blood to the tissues it serves, the body can sometimes compensate by developing and/or opening small specialised vessels to transfer blood form "healthier" arteries to the deprived tissues that are downstream of the blockage. The result of these special vascular networks that channel blood from one arterial branch to another is termed collateral circulation. The natural development of collaterals, however, is a gradual process, and heart patients often cannot produce them in the time or quantity necessary to relieve or reduce symptoms.
Enveloping the heart, these arteries provide the heart with its own nourishing supply of blood.
In traditional bypass operations, an incision is made along the midline of the chest through the breastbone. During part of the operation, heart and lung functions are assumed by a heart-lung machine. Blood vessels from another part of the body (usually the leg or chest wall)) are harvested or re-routed for grafting to diseased arteries to create conduits around blocked sections of the vessels.
Every year one million American develop atherosclerosis, partial or total blockage of arteries caused by deposits of fatty substances (plaques) in and on the walls of the vessels. The coronary arteries that supply blood to the heart are especially vulnerable.
An electrocardiogram is a recording of the heart's electrical activity. It is detected by electrodes attached to the skin, and recorded in waves that are displayed graphically. The ECG provides information on heart rate, rhythm, and function. An ECG may also indicate the presence of heart damage or inadequate blood and oxygen supply to the heart muscle, and abnormalities of heart structure.
Unfortunately, treatment to clear blockages often results in cell re-growth that can obstruct vessels again. This condition called restenosis occurs after 20 to 30 percent of PTCA procedures. (Source: The Merck Manual of Diagnosis and Therapy, Merck Research Laboratories, 1992). Repeat procedures are not uncommon and restenosis rates after repeat PTCA are as high as 50 percent.
For patients who have undergone CABG, repeat procedures are sometimes necessary. Six to ten percent of CABG procedures are now re-operations. However, re-operative mortality rates are two or three times those of the initial procedure and range from two to ten percent for second operations and up to fifteen percent for third and subsequent operations. Patients undergoing repeat procedures generally have more advanced coronary artery disease rendering the revascularisation process less effective. (Cath-Lab Digest, Jan/Feb, 1997).
Coronary perfusion scanning is a nuclear imaging technique used to evaluate coronary blood flow. Agents containing tracers such thallium-201 or technetium-99m are injected into the blood stream. The material is carried through the coronary arteries and into the capillaries of the myocardium (heart muscle), where it can be absorbed by the myocardial cells. Energy given off by the tracers is detected and processed by special computerized camera systems. Images are produced that show how the tracers were distributed within the heart muscle. Tissues that are well supplied with blood absorb more tracers, and record as the light areas on scan images. Portions of the heart muscle receiving diminished supplies of blood record proportionately lower levels of tracers, and are imaged with correspondingly less intensity (darker, or black). By comparing scans made while a patient is physically stressed (by exercise or pharmacologicals) with those recorded following a period of rest, diagnostic information regarding the condition of specific portions of the myocardium can be obtained.
During IECP® treatment, the air cuffs are simultaneously and quickly deflated at the beginning of each systole (ventricular contraction), relieving the compressive force that was being maintained by the inflated cuffs, this decompression allows vessels that had been "squeezed" by the cuffs to quickly reconfirm, and reducing resistance to the pumping action of the heart. This "unloading" of resistance during the hearts contraction phase (systole) increases the hearts output (volume of blood ejected with each contraction). The heart's oxygen demand is actually lowered as a result of the improved pumping efficiency.
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