PCI Booklet Draft 1

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Tests and Treatments for Your Heart Coronary angiogram and coronary angioplasty

This booklet is for patients who are talking to doctors or nurses about planned tests and treatments for their heart. The booklet is in three parts. It gives you information about your test, treatment, hospital stay and recovery.

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What is this booklet about?

Your doctor has advised that you should have a planned test and/or treatment for your heart.

This booklet gives you information about a test called coronary angiogram. It helps doctors to see if you have a heart problem.

The test results will help you, and your doctor, to choose the best treatment for you. One of these treatments is called coronary angioplasty with stenting. You will find out more about this treatment later in the booklet.

It is important that you understand;

What the tests and treatments are

How they may improve your health

What the complications are and their likelihood

Please take time to read this booklet so that you know what will happen and what will help you. You might want to read it more than once. Please keep this booklet and bring it with you to your next appointment.

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Contents We have split the booklet into 3 parts as it is a lot of information to take in. You may want to read one part at a time and talk to your family or friends. You might find it helpful to make a note of things you don’t understand. You can then talk this through with your doctor or nurse.

Part One Why do I need heart tests and/or treatments?

Part Two Getting ready for your hospital visit Part Three Going home and keeping healthy

To help you remember the most important information, we have summarised key points in highlighted boxes like this at the end of each section.

If you have any questions about a section in this booklet, jot them down to discuss with your nurse or doctor at your next appointment.

Please do let your nurse or doctor know if you need help to read medical booklets like this one.

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Part One Why do I need heart tests and/or treatments?

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What is coronary heart disease?

To help you understand why you need a heart test and/or treatment, let’s firstly explain what coronary heart disease is.

Blood pumped out of your heart carries oxygen. This oxygen-rich blood flows around your body in a network of tubes. These tubes are called blood vessels. Oxygen-rich blood is also needed by the heart muscle itself so it can work. Blood flows to your heart muscle in a network of blood vessels called coronary arteries. You can see the coronary arteries in the picture below.

Front

Left anterior descending artery

Back

Left circumflex artery Right coronary artery

Circumflex descending artery

Coronary heart disease, also called coronary artery disease or CAD, happens when the heart blood vessels become narrowed or blocked, so that blood flowing to the heart muscle is decreased.

This can cause a tightness, ache, or pain, in the chest, arm or jaw.

This feeling or symptom is called ‘angina’. Other angina symptoms include being short of breath, feeling tired and feeling sick. Some people don’t get any symptoms at all.

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What is a coronary angiogram?

Next, we will go through the heart test and treatments that your doctor has suggested you have.

Coronary angiogram is a diagnostic test for coronary heart disease. The test helps doctors ‘see’ blocked or narrowed parts of blood vessels that take blood to the heart. It gives information about blood flow and a ‘picture’ similar to the one below. The test helps to show what treatments you might need.

Coronary angiogram alone is not a treatment. But it is often done before, or as part of, a treatment called coronary angioplasty with stenting.

m image

Angiogra

What happens during a coronary angiogram?

A coronary angiogram is done in a cardiac catheterisation laboratory, ‘Cath Lab’ shown in the picture on page 7.

You will be awake during the test. You will have a numbing injection, (local anaesthetic), before a small tube is put into your 6

groin or wrist, through a small cut. Your doctor will tell you beforehand whether they will use your wrist or groin.

Cath Lab

Next, a smaller tube will be carefully passed through your blood vessel, up to the network of tubes/blood vessels in your heart muscle. A fluid dye, that can be seen by X-ray, is flushed into the heart blood vessels allowing x-ray pictures and blood flow measurements to be taken. The procedure can take between 30 minutes to 2 hours. You will need to lie still.

Radial artery (wrist)

Femoral artery (groin)

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What are the next steps?

The coronary angiogram will show what treatments you might need.

Coronary angiogram

If I have normal heart blood vessels

If I have abnormal heart blood vessels (blocked or narrowed)

No treatment or tests are needed

Medicine only

Coronary angioplasty and medicines

The next part of this booklet tells you about coronary angioplasty. You will be given more information about coronary artery bypass graft surgery if your doctor(s) thinks you should have this treatment.

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What is a coronary angiogram with stenting?

Next, we will go through the heart test and treatments that your doctor has suggested you have.

Coronary angioplasty with stenting is a treatment that ‘widens’, or ‘opens’, the blood vessels that take blood and oxygen to the heart muscle. This treatment increases blood flow to the heart muscle.

A stent, which looks like a tiny mesh tube, will be put inside the blood vessel to hold it open. Sometimes more than one stent is needed. The picture below shows a stent.

Stent example

There are different types of stents. Your doctor will be able to give you more information.

If a stent is used it will become part of the wall of the blood vessel and stay there forever.

What happens during the procedure?

A coronary angiogram test is done as the first part of coronary angioplasty treatment. Please read page 6.

To ‘open’ or ‘widen’ blood vessels, a tiny ‘balloon’ at the end of the tube is inserted up into the heart blood vessels and inflated. As the balloon gets bigger it squashes the fatty layers, which widens the blood vessel.

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The procedure usually takes 30 minutes to 2 hours and you will need to lie still.

Artery

Plaque

Stent

1 Balloon

2 Expanded stent

Stretching the blood vessel with balloon and stent

Inflated balloon

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Why might you have coronary angioplasty with stenting?

A coronary angiogram test is done as the first part of coronary angioplasty treatment. Please read page 6.

If you are on a waiting list for a planned coronary angiogram and/ or angioplasty with stenting, then you might have chronic coronary heart disease that is ‘stable’. Your doctor will be able to tell you more after the coronary angiogram test. A person with chronic coronary heart disease usually gets angina when they walk up a hill, feel stressed or upset or after eating a big meal. This goes away after resting for a few minutes. This is not a heart attack.

Angina can be controlled with medicines, but sometimes this treatment does not improve all symptoms. In this case, coronary angioplasty with stenting might be recommended. The main benefit of this treatment for this group of people is to take away angina discomfort so that people can have a better quality of life.

If you decide not to have coronary angioplasty, you should keep taking your medicines as advised.

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Part One Summary Insert summary points here

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Part Two Getting ready for your hospital visit

In Part 2 there is more information about what would happen ‘on the day’ if you, and your doctor/team, decide that coronary angiogram, or coronary angioplasty is right for you.

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Getting ready for your coronary angiogram test and coronary angiogram treatment Improve your heart health You can improve your heart health by living a healthier lifestyle. Read how you can start to make changes now on in part three (PAGE XX).

Eating and Drinking Usually you will not need to starve before the test/treatment. But this depends on what time you have the procedure. Please follow the information in your appointment letter.

Before going to hospital If you are taking blood thinning medicines (e.g.

Warfarin) your doctor might ask you to stop taking these tablets before your test. Unless advised by your doctor, please do not stop taking any medicines, or miss any doses. You might be asked to shave a small area around your groin the night before you come into hospital. If you are unable to do this, we will do this for you on the day of your procedure.

You will not be able to drive after the test/ treatment, so please arrange transport home after the treatment. To help you at home, you should arrange for someone to stay with you for the first 24 hours.

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Arriving at hospital Take your current medicines with you to the hospital. Leave jewellery/valuables at home (except wedding rings) or give them to a relative to look after. Bring dressing gown and slippers to wear after the procedure. Bring something to read or listen to. You can usually go home on the same day but sometimes you might need to stay in overnight, so please bring anything that you might need. E.g. toothbrush and nightwear.

What might I feel during the test and treatment?

1. Pain or discomfort at the wrist or groin You may feel pain or discomfort where the tube is put into your blood vessel, while you are having the test/ treatment, and afterwards. You will be awake during the procedure so please tell the doctor or nurse if you start to feel unwell. They can give you medicines if needed.

2. Feeling uncomfortable on the bed You will be lying flat on your back on a hard bed while you are having the test/treatment.

This might feel uncomfortable.

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3. Discomfort when the dye is inserted You might feel warm or flushed when the dye is inserted. You might feel that you need the toilet for a pee, but this should not last long. You should go to the toilet just before you have the procedure.

4. Pain or discomfort in your chest during coronary angioplasty treatment When the balloon is inflated to stretch open the blood vessel in your heart, you might have chest discomfort. This should not last long.

5. Bruising where the tube was put into your blood vessel This will be either at the wrist or groin entry site. Bruising is more common if the tube is put in through the groin. Most people will get a bruise. This should disappear in 2-3 weeks.

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What happens afterwards?

To stop any bleeding, pressure will be applied to the area where the tube was put into your blood vessel. This will be at your wrist or groin.

Wrist: A band may be placed around your wrist for 2 hours and slowly released.

Groin: You will usually need to lie flat on your back for a few hours after the procedure. When the tube is taken out, a nurse will put pressure on the area. A special pressure or closure device is often used to help the area to heal.

You will be taken to a ward or recovery area and asked to rest in bed for 4-6 hours until you have recovered. Usually, you can go home on the same day but sometimes you might need to stay in overnight.

What are the possible complications of the test/treatment?

The risk of serious complications during or after a coronary angiogram and/or angioplasty is small.

However, it is important that you fully understand the risks before you decide to have the procedure. Page 17 goes through these risks.

The risks of complications are higher if you are older or have kidney disease, diabetes, more than one narrowed/blocked heart blood vessel or a history of serious heart disease. Your doctor or nurse will talk to you about your individual risk. This will help you to make a decision together about the best plan for you.

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Risks of complications during the procedure include: Damage to kidneys

Allergic reaction to dye

Emergency open heart surgery

1 XX 1 XX 1 XX IN

IN

IN

Heart attack, stroke Damage to the blood Heart blood vessel or death vessel at the wrist/groin too small for stent

1 XX 1 XX 1 XX IN

IN

IN

Risks of complications after the procedure include: Bleeding that won’t stop

A blood clot that forms in Part of blood vessel the stent, causing a heart narrows again attack (restenosis)

1 XX 1 XX 1 XX IN

IN

IN

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Will the treatment fix me?

Coronary angioplasty opens narrow/blocked blood vessels and increases the flow of blood to the heart. The main benefit of this treatment is to take away the angina discomfort, so you can have a better quality of life. However, the heart disease that caused the narrow/blocked blood vessel is still there. This means that you might need another angioplasty or a coronary artery bypass surgery in the future.

For some people, coronary angioplasty does not improve angina.

In this situation, your doctor will tell you if other treatments are available, such as, coronary artery bypass surgery.

The good news is that living a healthy lifestyle and taking your heart protective medicines can help to keep your heart vessels from narrowing or blocking again. The medicines that make your blood less ‘sticky’ are very important and should not be stopped even for a day. You can read more about heart protective medicines and how to stay healthy in part three.

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Part Two Summary Insert summary points here

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Part Three Going home and keeping healthy

In Part 3 there is more information about what you need to think about when you go home and common questions people ask during early recovery. When you leave hospital, you may also be given a date for a follow-up appointment to check on your progress.

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What do I do if I get the same sort of pains again?

If you have coronary angioplasty treatment, it is quite common to feel flickering pains in your chest that last for a few seconds. If you get pain that lasts longer than a few minutes, you should follow the ’15-minute rule’.

‘The 15-Minute Rule’

ONE Sit down, rest and try to relax TWO If pain is present and you have been prescribed GTN (glyceryl trinitrate), take two puffs of the spray or one tablet under the tongue and wait 5 minutes.

THREE If after 5 minutes you are still in pain or discomfort, take another two puffs of the spray (or one tablet) under your tongue and wait 5 minutes.

FOUR If you are still in pain or discomfort, after a total of 15 minutes, dial 999 to call for an ambulance.

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Things to watch out for in the first week home Managing your wound Did you know that a small cut is made in your skin at your groin or wrist, during coronary angiogram and angioplasty? Please read part one again if this is new to you. When you go home, problems with the wound are unusual, but we need to tell you what to do in case they happen.

Wrist (Radial artery) 1. Rest your arm: this will help to heal the opening where the tube was put in. For example, do not lift heavy bags or strain your arm for 3 days.

2. Check your wound: if the opening where the tube was put in is very red, swollen, or feels hot or painful, contact your doctor as soon as possible.

3. Check your hand: if your hand looks different, becomes cool, pale or painful, please contact your doctor immediately.

4. Bleeding: sit down, lift your arm above your head, apply a clean towel to the opening and press firmly for 10 minutes. If it does not stop bleeding, dial 999 or ask someone to take you to a Minor Injuries Unit or Emergency Department. dial 999 to call for an ambulance.

Groin (femoral artery) 1. Rest and avoid any physical activity that might increase the pressure in your groin for 2 days. For example, lifting heavy bags.

2. Check your wound: a dark bruised area is common which may be uncomfortable for 2-3 days. If the opening where the tube was

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put is red, swollen, or feels hot or painful, contact your doctor as soon as possible.

3. Check your foot: if your foot looks different, becomes cool, pale or painful, please contact your doctor immediately.

4. Bleeding: lie flat, ask someone to apply a clean towel to the opening and press firmly for 10 minutes. If it does not stop bleeding, dial 999 for an ambulance.

Managing your heart medicines Please make sure that you understand what medicines you need to take. Always ask if you are not sure. Your local pharmacy can always give you information. If you have a coronary angioplasty you may need to take Aspirin together with one of the medicines below: Clopidogrel, OR Ticagrelor OR Prasugrel This is often called Dual Antiplatelet Therapy (DAPT). These medicines thin the blood to reduce the risk of blood clumping around the stent (if you have had one put in). If you normally take Warfarin, this will be discussed with you on discharge.

VERY IMPORTANT

Do not stop taking these medicines, or miss any doses, unless advised by your doctor. Your risk of a heart attack is increased if the medicines are stopped suddenly.

Heart protective medicines The table on the next page tells you about some of the heart protective medicines that your doctor might prescribe. Some medicines have side effects. For more information, please talk to your doctor, nurse or pharmacist and read the information leaflet that comes with the medicines.

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This medicine temporarily widens your heart blood vessels. It acts fast to reduce pain and discomfort.

These medicines make your heart beat slower (lower your heart rate) and with less force.

These medicines help to treat angina and lower blood pressure, by allowing your blood vessels to relax. This means more blood can flow through your blood vessels to your heart muscle.

GTN mouth spray or tablet

Bisoprolol Metoprolol Atenolol

Nifedipine Amlodipine Felodipine Diltiazem Verapamil

Short acting nitrate

Beta-blockers

Calcium channel blockers

Other angina drugs

These medicines help to thin your blood, which allows your blood to flow more easily. This means your blood will be less likely to make a dangerous blood clot.

These medicines help your heart by either making your heart beat slower (lower your heart rate) or relaxing your blood vessels. This allows more blood to flow through your blood vessels to your heart muscle.

Ivabradine Simvastatin Nicorandil Ranolazine

Statins

Aspirin Clopidogrel Ticagrelor Prasugrel

These medicines help to reduce your risk of having a heart attack or stroke by lowering the amount of cholesterol in your blood.

Atorvastatin Fluvastatin Pravastatin Rosuvastatin

Anti-coagulants

These medicines help to treat angina and lower blood pressure, by allowing your blood vessels to relax. This means more blood can flow through your blood vessels to your heart muscle

Ramipril Enalapril Lisinopril Perindopril

AngiotensinConverting Enzyme (ACE) inhibitors

How do they help me?

Common names

Type of Medicine

The medicines you have been given will help to protect your heart. It is important that you take your medicines as advised.

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Going forwards When can I drive again?

How quickly you can drive again depends upon:

1. What test and treatment you have had, 2. How quickly your wound heals (wrist or groin), 3. What sort of vehicle you drive You will need to talk to your car insurance company before you go back to driving. If driving is part of your job (e.g. Taxi driver), you will need to contact the organisation that has given you your licence, such as the DVLA and/or LPHCA. Car or motorbike: After having a coronary angiogram test, you must stop driving for up to 3 days. After having coronary angioplasty, you must not drive for 7 days.

Bus, coach or lorry: You must tell the DVLA and stop driving for 6 weeks if you have had a coronary angioplasty. After 6 weeks you will need to see your doctor or GP before you can start driving again.

Ask your doctor or nurse to complete this You can start driving a car or motorcycle again on……………………………………………………………......

If you drive a bus, coach or lorry (HGV or PSV licence) you will need to ……………………………………………………………………………………… …………………………………………………………………………………………………… ………………………………………………………………………………………….

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When can I get back to work?

Please talk to your doctor or nurse before you leave hospital. The amount of time you need depends on what sort of job you do.

When can I go on holiday?

Please talk to your doctor or nurse before you leave hospital. You will need to tell your travel insurance company about any medical conditions and tests/treatments you have before you go on holiday abroad.

Ask your doctor or nurse to complete this You can go on holiday abroad again from …..…………………………………………………………..

When can I do exercise?

You should avoid strenuous activity and heavy lifting for at least one week after your test and treatment. Please read page XX for more information. Your doctor or nurse will be able to tell you more.

When is it safe to have sex?

Sexual activity is an important part of life for some people but not necessarily everybody. Sex is no more likely to trigger a heart problem than any other form of activity. Sex is just another form of exercise. You should wait until your wound has healed before having sex. This might take a few days (wrist wound) to at least one week (groin wound). Please talk to your doctor or nurse for more information.

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What should I expect to feel when I go home?

People have different reactions after having a coronary angiogram or angioplasty. It is common to feel emotional, worried or down about having heart problems. It is important to have support from your family, friends or carers. Further support is available from the British Heart Foundation and your local cardiac rehabilitation.

Many people find cardiac rehabilitation helpful and supportive. It is a good way to socialise and meet people who have had a similar experience to you.

Websites: www.bhf.org.uk/informationsupport/heart-helpline www.cardiac-rehabilitation.net/ Telephone: 0300 330 3311

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What can I do to slow down the narrowing in my heart blood vessels?

Quit smoking

Eat a healthy diet

Be drink aware

Take medicines correctly

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Cardiac rehabilitation After having a coronary angioplasty, your doctor might prescribe cardiac rehabilitation. To help you recover, it is important that you attend cardiac rehabilitation. Classes can include supervised exercise, dietary advice, education, and emotional support. You can learn how to maintain a healthy weight, and keep blood pressure and cholesterol levels from rising. Ask your doctor, nurse or GP to tell you more. You can find your nearest cardiac rehabilitation programme at this website: http://www.cardiac-rehabilitation.net/ or call the British Heart Foundation Heart Helpline on 0300 330 3311.

Quit tobacco smoking Tobacco smoking decreases the amount of oxygen that is delivered to your heart muscle. This puts further stress on your heart. Please give serious thought to stopping. This is an important decision you could make to improve your health now and in the future. When you smoke tobacco, your body gets nicotine very quickly. Many people find it easier to stop smoking when they use nicotine replacement therapy, such as nicotine patches or gum. Your doctor or nurse can help you to stop smoking.

More help is available at; NHS Smokefree: www.nhs.uk/smokefree/ Quitline: 0800 002200 http://www.quit.org.uk/ Take your ‘heart medicines’ as advised by your doctor Taking your medicines will reduce your risk of having future heart problems. Your doctor, nurse or pharmacist can explain how the medicines work and any side effects. Information and support are also available at the British Heart Foundation www.bhf.org.uk/ Helpline: 0300 330 3311 29

Get more active Regular physical exercise has been shown to have many positive effects on both the body and the heart. It can reduce body weight, improve blood pressure, reduce cholesterol levels, improve blood sugar levels and increase muscular strength. People feel more energetic and happier when they exercise regularly and because of these benefits it should be as important as taking your heart medicines.

How soon you can start to do physical activity and exercise will depend on the test/treatment you have had, your general health and your fitness levels. You should rest and avoid lifting heavy objects in the first few days after your test/treatment. Once your wound (wrist or groin) has healed, you can start gentle exercise in the form of walking. Progress after this depends on your fitness level. You should always warm-up slowly before exercise.

In general, you should try to: Do some activity every day, such as walking or housework.

Build up to 150 minutes (2 ½ hours) of activity each week.

For example, you could do 3 lots of 10 minutes of activity on 5 days each week.

The type of activity you do will depend on your health and fitness level. Suitable activities include walking, jogging, cycling, dancing, swimming, golf and gardening. Try choosing an activity that makes you feel warmer, breathe harder and makes your heart beat faster. You should still be able to talk during the activity.

Build your muscle strength using light weights.

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For specific advice on activities, such as sport or competition, please contact your cardiac rehabilitation team or your doctor.

The most important point is that exercise is taken regularly in any form and that you enjoy it enough to continue as a lifelong commitment rather than a short-term fix.

The best way to get support and encouragement to help you get back to exercise is by going to your local cardiac rehabilitation classes (if available). Your doctor might prescribe cardiac rehabilitation as part of your recovery (read page 29).

Eat a healthy diet Eating healthier and following a Mediterranean diet helps to improve the health of the blood vessels and can help with weight loss. It can also help reduce the risk of further heart disease. Your doctor, nurse or dietician can advise you about how to improve your diet. More information is available at NHS Eat Well https:// www.nhs.uk/live-well/eat-well/ Here are some top tips: Don’t put salt on food. Most already contain salt.

Have 5 portions of fruit and vegetables every day.

Eat oily fish (salmon, mackerel, sardines, tuna, kippers) 1-2 times per week (and we don’t mean the ones from the fish and chip shop)!

Have less fat, especially saturated fats. This includes cheese, cream, fatty meats. Replace these with unsalted nuts and seeds.

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Eat foods with more wholegrain fibre such as brown bread and brown pasta.

Cut down on sugary foods and drinks. Don’t add sugar to hot drinks.

Starchy foods

Fruits & vegetables

Protein rich, non-dairy foods

Oils & spreads Dairy & alternatives

Be drink aware Too much alcohol can be harmful to your heart. You should not drink more than 14 units of alcohol each week. You should have several alcohol-free days each week and you should avoid binge drinking (e.g. more than 4 units in one sitting) 1 unit of alcohol = half pint of beer (normal strength) OR small glass of wine (125mls) OR small glass of sherry OR a single pub measure of spirits (25mls) Your doctor or nurse can help you to drink less alcohol.

More help is available at Drink aware 0300 123 1110 or www.drinkaware.co.uk/ 32

Part Three Summary

Insert summary points here

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Further information & support www.nhs.uk

www.bhf.org.uk

Heart Helpline 0300 330 3311

Cardiac Rehabilitation www.cardiac-rehabilitation.net

Hospital Trust Information

Disclaimer: This booklet is for information purposes only and should not be used as an alternative to professional medical advice. You should talk to a health professional about your own care and needs.

Created: Aug/Sept 2020

| Review Date:

This booklet has been created by academics at the University of Huddersfield upon consultation with patients, service users and health professionals, and informed by findings from an NIHR RfPB research project grant (PB-PG-0712-28089). Designed by Nifty Fox Creative, 2020.