PCI Booklet English

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.

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;

How they may What the possible What the tests and improve your health complications are treatments are Reading this booklet will help you to understand what might happen and what will help you. You might want to read it more than once. Let your nurse or doctor know if you usually need help to read medical booklets like this one.

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Contents We split this 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. Please keep this booklet and bring it with you to your next appointment.

Part One

What heart tests and/or treatments might I need?

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 part.

You can use this space to write down any concerns or questions you want to ask your doctor or nurse at your next appointment.

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Part One What heart tests and/or treatments might I need?

In Part 1, we explain about the coronary angiogram test and coronary angioplasty treatment and why it is used.

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Part One

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 properly.

Blood flows to your heart muscle in a network of blood vessels called coronary arteries. You can see from the picture below that the coronary arteries run along the surface of the heart.

The heart blood vessels (coronary arteries) Aorta

Right coronary artery

Left coronary artery

Circumflex artery

Left anterior descending artery 4

Part One

Coronary heart disease, also called coronary artery disease, happens when the coronary arteries become narrowed or blocked.

This ‘clogging’ means that the amount of blood flowing to the heart muscle is decreased. This can cause feelings of tightness, an ache, or pain, in the chest, arm or jaw.

These feelings, sensations or symptoms are called ‘angina’ and can sometimes feel like indigestion. Other angina symptoms include being short of breath, sweating, tiredness and feeling sick. But some people don’t get any symptoms at all.

Symptoms of angina Sweating and tiredness Feeling short of breath

Narrowed heart blood vessels

Tightness or pain in jaw, arm or chest

Feeling sick/ experiencing indigestion sensations

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Part One

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

coronary arteries 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.

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

Cath Lab

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Part One

You will be awake during the test, but may be given some medication to help you relax. You will have a numbing injection, (local anaesthetic). Then a small tube is passed through your skin into the blood vessel at either your wrist or groin. Your doctor will tell you beforehand which will be used.

Next, a thin, flexible tube (called a catheter) will be carefully passed through your blood vessel, up to the coronary arteries on the surface of your heart muscle. A fluid dye, which can be seen by X-ray, is flushed into the coronary arteries. This allows x-ray pictures and blood flow measurements to be taken. The angiogram test usually takes between 15 minutes to 1 hour. You will need to lie still during this time. If you are unable to lay flat please discuss this with your Doctor/Nurses.

What happens during a coronary angiogram

Radial artery (wrist)

Angiogram picture of coronary artieries

Entry point Entry point

Femoral artery (groin)

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Part One

What are the next steps?

The coronary angiogram will show what treatments you might need.

You will be given more information about coronary artery bypass graft surgery if your doctor(s) suggests this treatment. The next

part of this booklet tells you about coronary angioplasty.

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What is a coronary angioplasty with stenting?

Part One

Coronary angioplasty with stenting is a treatment that ‘wid-

ens’, or ‘opens’, the blood vessels that take blood and oxygen to the heart muscle. This treatment increases blood flow to the heart muscle.

A coronary angiogram test is done as the first part of coronary angioplasty treatment. This shows the doctor which coronary artery may need treatment.

Once a narrowing is found in the coronary artery a tiny ‘balloon’ is filled with fluid. As it gets bigger the fatty build-up (known as plaque) is squashed into the blood vessel wall. This widens the blood vessel so more blood can flow through.

Usually, but not always, a stent will be put inside the blood vessel to hold it open. A stent looks like a tiny mesh tube as shown below.

Sometimes more than one stent is needed.

Angioplasty with stenting

Coronary artery Plaque

1 Stent

2 Balloon

3 Inflated balloon

4 Expanded stent 9

There are different types and sizes of stents. This picture shows the size of a stent compared to the size of a 1p coin. Your doctor will give you more information about the type of stent you might need.

Part One

The balloon is removed but the stent will stay there forever. It becomes part of the blood vessel wall. The treatment can take between 15 minutes to 2 hours. You will need to lie still during this time.

Stent example

Why might you have coronary angioplasty with stenting?

If you are on a waiting list for a planned coronary angiogram and/ or angioplasty with stenting, you may have long-standing coronary heart disease that is ‘stable’.

A person with ‘stable’ coronary heart disease may experience angina (see page 5) 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 alone is not enough to manage it. In this case, coronary angioplasty with stenting might be recommended. The main benefit of angioplasty for this group of people is to take away unpleasant angina symptoms to improve their quality of life.

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

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Part One

Part One Summary • Narrowed or blocked coronary arteries cause coronary heart disease. Angina is a symptom caused by reduced blood flow to the heart muscle.

• A coronary angiogram is a test that shows the health of your coronary arteries and the blood flow through them • Coronary angioplasty with stenting is a treatment to ‘open’ or ‘widen’ coronary arteries to improve blood flow through them.

Your questions or concerns

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Part Two Getting ready for your hospital visit

In Part 2 we explain what you can expect ‘on the day’ if you agree to have a coronary angiogram or coronary angioplasty.

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Getting ready for your coronary angiogram test and coronary angioplasty treatment

Eating and Drinking Part Two

Usually you will not need to go without food before the test/ treatment. Please follow the information in your appointment letter.

Before going to hospital

If you are taking blood thinning medicines your doctor/nurse will discuss stopping these. But please do not stop taking any medicines, or miss any doses, unless advised by your doctor or nurse.

Arriving at hospital

• Have a shower/bath before you come in.

• Bring your current medicines with you • Leave jewellery/valuables at home • Bring dressing gown and slippers to wear • Bring something to read or listen to • Please bring anything that you might need in the unlikely event that you have to stay overnight • Go to the toilet before your test/treatment

Leaving hospital

You will not be able to drive after the test/ treatment, so please arrange transport home afterwards. If possible arrange for someone to stay with you for the first 24 hours when you come home to help you.

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Improve your heart health

Part Two

Living a healthier lifestyle and taking your medications are the most important things you can do to keep the inside of your coronary arteries healthy.

(Read more in part three.)

What might I feel during the test and treatment?

You will be awake and able to talk during the coronary angiogram and/or angioplasty. Please tell the doctor or nurse if you start to feel unwell. They can give you medicines if needed.

1. Discomfort at the wrist or groin

You may feel discomfort where the tube is put into your blood vessel, while you are having the test/ treatment, and afterwards.

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.

3. Discomfort when the dye is inserted

You might feel warm or flushed, or get the feeling that you need to have a pee when the dye is injected. But this should not last long.

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4. Pain or discomfort during coronary angioplasty treatment

When the tiny balloon is inflated to stretch open the blood vessel in your heart, you might have chest discomfort. Let the doctor/nurse know and they can give you some medication.

Part Two

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

This should disappear in 2-3 weeks.

What happens afterwards?

To stop any bleeding, pressure will be applied to the puncture /entry site, in either the wrist or groin.

Wrist: A tight compression band (shown in the picture below) may be placed around your wrist for up to 3 hours and slowly released.

Wrist compression band Groin: You will usually need to lie flat on your back for a few hours

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after the procedure. When the tube is taken out, a nurse will put pressure on the area. A special pressure or closure device is sometimes used to help the area to heal (shown in the picture below).

Part Two

Groin artery closure device

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?

Most medical treatments carry some risk of complications.

It is important that you understand what the risks and benefits are of treatment before you decide to go ahead. The risk of serious complications during or after a coronary angiogram and/or angioplasty is small.

However, some factors increase your risk of having complication.

Older people and those with serious heart disease or other medical conditions e.g. kidney disease and diabetes are at higher risk. Your cardiology team will talk to you about your individual risk. This will help you to make a decision together about the best plan for you.

To help you prepare for this discussion we have provided you with information about the risks and the likelihood of these happening to the ‘average’ person.

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Example

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1 in 100 means that the complication

Part Two

is likely to happen to one person in every 100 people who have the test/ treatment. This also means that it is likely that 99 people out of 100 people will NOT experience the complication.

100 Risks of complications DURING the procedure include:

Damage to kidneys: Allergic reaction to dye: Emergency open heart surgery: Heart attack, stroke or death: Damage to the blood vessel or bleeding that won’t stop at the wrist: Damage to the blood vessel or bleeding that won’t stop at the groin:

1 in 100 1 in 200 1 in 3000 1 in 400 1 in 333 1 in 67

Risks of complications between 1 and 5 years AFTER the coronary angioplasty treatment:

A blood clot forms in the stent, causing a heart attack:

1 in 100

Part of the blood vessel narrows again (restenosis):

1 in 20 17

Will the treatment fix me?

Coronary angioplasty opens narrow/blocked coronary arteries which increases blood flow to the heart. The main benefit of this treatment is to take away the discomfort of angina, so you can have a better quality of life.

Part Two

However, the heart disease that caused the narrow/blocked coronary artery is still there. This means that some people might need another coronary angioplasty or a coronary artery bypass surgery in the future.

For some people the coronary artery that needs treatment is too small for a stent to be inserted. For other people, coronary angioplasty treatment does not improve angina symptoms. In these situations, your doctor will tell you if other treatments are available, such as, medications or 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 • Coronary angioplasty is not a cure for coronary heart disease. The aim of the treatment is to take away the angina discomfort, so you can have a better quality of life.

Part Two

• The risk of complications during or after a coronary angiogram and/or angioplasty is small. Please ask your doctor to tell you about your individual risk.

• You will not be able to drive after the test/ treatment, so please arrange transport home after the treatment.

• Living a healthy lifestyle and taking your heart protective medicines will improve your heart health and keep the inside of your coronary arteries healthy.

Your questions or concerns

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Part Three Going home and keeping healthy

In Part 3 we explain what you need to know about during your first few weeks at home.

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

After having 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’

Part Three

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

Then wait 5 minutes.

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

FOUR If you are still in pain or discomfort, after a total of 15 minutes, dial 999 to call for an ambulance. Do not drive yourself to hospital.

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Things to watch out for in the first week home Managing your puncture wound

A small tube is passed through a puncture in your skin into the blood vessel at either your wrist or groin during a coronary angiogram and angioplasty. (See Part 1.) 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)

Part Three

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 in the first week after your procedure 2. Check your puncture 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 and forearm: if your hand or forearm 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 or dial 999 to call for an ambulance.

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Groin (femoral artery) 1. Rest and avoid any physical activity that might increase the pressure in your groin for 2 days. For example, do not lift heavy bags in the first week after your procedure.

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

Part Three

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 are taking. Always ask if you are unsure. Your local pharmacy can always give you information. If you have had a coronary angioplasty you may need to take Aspirin together with one of the medicines on page 24: 23

Clopidogrel, OR Ticagrelor OR Prasugrel When one of these medicines is taken as well as aspirin, it is called ‘Dual Antiplatelet therapy (DAPT)’. These medicines thin the blood to reduce the risk of blood clumping in the stent or at the site of the treated artery. If you normally take Warfarin, this will be discussed with you before you go home.

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

Part Three

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. Please tell your doctor if you get unwanted side effects as you might be able to change to a different medicine.

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Type of Medicine Short acting nitrate

Common names

How do they help me?

GTN mouth spray or tablet

Widens coronary arteries temporarily to improve blood flow through them and relieve angina.

Bisoprolol Metoprolol Atenolol Nifedipine Amlodipine Calcium channel Felodipine blockers Diltiazem Verapamil Beta-blockers

Part Three

AngiotensinConverting Enzyme (ACE) inhibitors

Ramipril Enalapril Lisinopril Perindopril

Statins

Atorvastatin Fluvastatin Pravastatin Rosuvastatin

Other angina drugs Anti-platelet drugs

Ivabradine Simvastatin Nicorandil Ranolazine Aspirin Clopidogrel Ticagrelor Prasugrel

Slows down the heart rate.

Relaxes and widens coronary arteries to improve blood flow.

Relaxes veins and arteries to improve blood flow through them. Also lowers blood pressure.

Reduce ‘bad’ Low Density Lipoprotein cholesterol and potentially heal fatty plaques inside coronary arteries.

Slows down the heart rate without affecting the way the heart pumps blood.

Thin your blood to make blood flow more easily and reduce clotting.

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Going forwards Your cardiac team are an important source of information and can help you with any questions you have about the topics listed below.

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

Part Three

You will need to inform 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 at least 6 weeks if you have had a coronary angioplasty. You will need to see your doctor or GP before you can start driving again.

When can I get back to work?

You will probably need 1 week off work, but this depends on what sort of job you do.

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When can I go on holiday?

You will need to tell your travel insurance company about any medical conditions and tests/treatments you have before you go on holiday abroad.

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 30 for more information.

When is it safe to have sex?

Part Three

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

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 tired, worried or a bit down about having heart problems. It is important to have support from your family, friends or carers. The British Heart Foundation and your local cardiac rehabilitation team are important sources of support. Look on the back page of this booklet for useful

websites and helplines to support you.

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

Part Three

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 should refer you to cardiac rehabilitation if it is available. People who attend exercise based cardiac rehabilitation are more likely to live longer than those who do not. Classes help people by providing supervised exercise training, advice about healthy lifestyle and psychological support. Many people find it helpful to meet people who have shared a similar experience.

Cardiac rehabilitation is an important part of your treatment and recovery and you should try to attend all classes. 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.

Part Three

Quit tobacco smoking Quitting tobacco smoking is one of the most important lifestyle changes you can make. The chemical in tobacco smoke damage the inside of your coronary arteries, makes your blood sticky and more likely to clot and decreases the amount of oxygen delivered to your heart muscle. Nicotine is highly addictive. People who use nicotine replacement therapy, such as nicotine patches or gum, are four times more likely to quit successfully compared to those who don’t.

Your doctor or nurse can provide support and guidance to help you to stop smoking.

More help is available at: NHS Smokefree: www.nhs.uk/smokefree/ Quitline: 0800 002200 http://www.quit.org.uk/

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Take your ‘heart medicines’ as advised by your doctor Taking your heart protective medicines will reduce your risk of having future heart problems. Your doctor, nurse or pharmacist can explain how the medicines work and possible side effects.

Information and support are also available at the British Heart Foundation www.bhf.org.uk/ Helpline: 0300 330 3311

Get more active Regular exercise works in lots of ways to keep your heart healthy.

It can help to:

Part Three

• reduce body weight • lower blood pressure • reduce cholesterol levels • improve blood sugar levels • increase energy levels and reduce stress • increase muscle strength 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. Before you start get advice from your local cardiac rehabilitation team (see page 30) or a health professional.

In the first two weeks immediately following discharge home, your body needs time to recover, but even at this early stage exercise can be taken in the form of gentle walking once your puncture wound has healed.

To help you think about getting your exercise at the right level you should aim to be a little bit short of breath, but can still easily talk. Feelings of chest tightness, dizziness, palpitations and shortness of breath are warning signs which mean that you should stop and get medical advice

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Try to reduce the amount of time you are sitting down.

Progress after the first 2 weeks of recovery is dependent on your individual fitness levels, but provided you warm up slowly before exercise and are mindful of any warning signs you can start to build the intensity of your exercise.

Part Three

Following a recovery period of 6-8 weeks there are very few activities that are actively discouraged and you are limited only by your physical fitness and general health. Please contact your cardiac rehabilitation team or a suitable health professional for specific advice.

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.

Eat a healthy diet Eating healthier and following a Mediterranean diet (shown on page 32) helps to improve the health of the coronary arteries and can help with weight loss. It can also help reduce the risk of further heart disease. More information is available at NHS Eat Well https://www.nhs. uk/live-well/eat-well/ 31

Mediterranean Diet LESS OFTEN

Red meats, sweets, fried foods.

Don’t put salt on food.

Cut down on sugary foods and drinks.

Don’t add sugar to hot drinks.

WEEKLY

Poultry (Chicken, turkey), eggs, and yoghurt. Cheese and cream contain high amounts of saturated fats, which are not good for you. Only small amounts of these should be eaten.

1 - 2 times each week - oily fish (salmon, mackerel, sardines, tuna, kippers) and seafood

EVERY DAY

Part Three

OFTEN

Base each meal around these foods. Have 5 portions of fruit and vegetables every day. Drink water regularly.

EVERY DAY

Vegetables, fruits, whole wheat grains, olive oil, beans, nuts, legumes and seeds, herbs and spices. Eat foods with more wholegrain fibre such as brown bread and brown pasta

For information on healthy diets suitable for different cultures (e.g. South Asian diet), please visit www.heartuk.org/healthy-living 32

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 at least 2 alcohol-free days each week and avoid binge drinking (e.g. more than 6 units in one sitting).

1 unit of alcohol = 10ml of pure alcohol. This is equal to 2 teaspoons Different alcoholic drinks contain different amounts of units, as shown in the examples below:

Beer | 4% 568ml, (1 pint) = 2.3 units Part Three

Beer | 5% 330ml = 1.7 units

Cider | 4.5% 568ml, (1 pint) = 2.6 units

Wine | 13% 175ml = 2.3 units

Spirit | 40% 25ml = 1 unit Please talk to your doctor or nurse if you want further advice on how to drink alcohol responsibly. More help and support is available at Drink aware 0300 123 1110 or www.drinkaware.co.uk

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Part Three Summary • Make healthy lifestyle changes to improve your heart health.

• Take your heart protective medicines as prescribed.

• Rest and do not lift heavy bags for one week after having an angiogram or angioplasty.

• Attend cardiac rehabilitation andfollow-up appointments

Part Three

• Follow the 15-minute rule if you get chest pain that lasts longer than a few minutes.

Your questions or concerns

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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.