A PATIENTS GUIDE TO CORONARY ANGIOPLASTY AND STENTING

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1 USEFUL TELEPHONE NUMBERS Ward numbers: Ward 28: (Direct line) Ward 33: (Direct line) Ward 33a: (Direct line) Ward 34: (Direct line) Cardiac Rehabilitation Help lines: Glenfield: Leicester Royal: Leicester General: Derby City: Derby Royal: Kings Mill: Lincoln County: Pilgrim: Queen s Burton: Kettering: Grantham: George Elliott: CARDIOLOGY UNIT A PATIENTS GUIDE TO CORONARY ANGIOPLASTY AND STENTING This booklet has been produced by: The Cardio-Respiratory Patient Information Group Updated: July 2006 University Hospitals of Leicester NHS Trust Glenfield Hospital Groby Road Leicester LE3 9QP Telephone: Fax: Minicom: University Hospitals of Leicester NHS Trust Glenfield Hospital

2 TRANSLATION If you would like this information in another language or format, please contact the Service Equality Manager on The DVLA states that you should not drive a car for 1 week from the date of procedure (no notification to DVLA required), a bus or lorry for 3 months, (notification to DVLA required) after your angioplasty/stent. AFTER DISCHARGE Your doctor may arrange for you to be seen again in the out patients department to review your progress. Your local Cardiac Rehabilitation team are also available to help and support you in your recovery and to reduce your chances of further problems in the future. Their number is on the back page of this booklet. MEDICATION POST PROCEDURE Haddaad rabto warqadan oo turjuman oo ku duuban cajalad ama qoraal ah fadlan la xiriir, Maamulaha Adeegga Sinaanta Eĝer bu broşürün (kitapçıĝın) yazılı veya kasetli açıklamasını isterseniz lütfen servis müdürüne telefonundan ulaşabilirsiniz. is one of the first interactive web sites for heart patients and their relatives and friends in the UK. This site will offer heart and health related information available It is essential for Aspirin and Clopidogrel to be taken for as long as recommended by your doctor following coronary artery stent insertion. You will need to continue your other medication as before the procedure unless your doctor changes them. You should not stop your Clopidogrel unless advised to by your cardiologist. You should tell any doctor treating you that you have a stent and are on Clopidogrel. CHEST PAIN AFTER DISCHARGE For sometime after there is a small risk of clotting on the stent, which would then block it, leading to chest pain and a possible heart attack (Myocardial Infarction). After 1 to 6 months a film of cells covers the stent and the risk of clotting of stent thrombosis is over. It is possible to re-open an occluded stent but this needs to be done quickly. Should you develop chest pain during the first four weeks after leaving hospital, you should telephone the ward where you had stayed and speak to the doctor who was caring for you to seek further advice. - 10

3 YOUR WOUND Leave your dressing or your plaster on for 2 days after your procedure and then remove it and leave the puncture site exposed to heal. Some bruising and discolouration may develop at the site but it is not serious. Paracetamol can be taken for minor discomfort. However, if at any stage you are concerned about your wound site, may be it is very swollen or has an enlarging painful bruise over it, please contact either your GP or the ward you stayed for advice. WHAT ABOUT MEDICATION FOR STENT IMPLANT? You will be prescribed a medicine called Clopidogrel, which stops blood cells (platelets) sticking together on the stent implanted in your coronary artery. You will be given specific instructions for how long you will need to take this for. The hospital pharmacy will provide you with a supply for 1 month, so you will need to get a repeat prescription from your GP if you are required to take it for longer. Your doctor, nurse or pharmacist on the ward will advise you. You will need to continue to take aspirin as you have been doing. INTRODUCTION This booklet has been developed to help you understand what to expect before, during and after your coronary angioplasty and stent implant. If you have any questions that the booklet does not answer, please do not hesitate to ask the nursing or medical staff who are looking after you. CORONARY ARTERY DISEASE Coronary artery disease is the term used to describe furring and narrowing of the arteries (blood vessels) in the heart that provide blood flow to the heart muscle. The gradual build up of fatty materials in the inner lining of the arteries is the most common cause of narrowing of the coronary arteries. Angina is the name given to the symptoms that happen when the build up is enough to restrict the blood flow down the artery and therefore the heart muscle does not receive enough blood and oxygen. These symptoms may include chest pain or discomfort as well as breathlessness. Diagram of the Heart: ON DISCHARGE When you return home which should be within 1 or 2 days following your procedure, you should take it easy for at least 2 days and slowly increase your activity. Ask your doctor or nurse about returning to work as this often depends on your occupation, but the general rule is that we advise you to remain off work for 1 week. Avoid lifting heavy objects and activities such as hoovering, mowing and lifting heavy shopping for 2 days and then return to normal activity, as you feel able. Information is available on the ward on lifestyle adjustment or through your local Cardiac Rehabilitation team

4 WHAT IS A CORONARY ANGIOPLASTY AND STENTING? Coronary angioplasty and stenting is a specialised treatment used to stretch the coronary artery and therefore reduce or unblock narrowings. You may also hear it referred to as PCI (Percutaneous Coronary Intervention). This procedure is undertaken in the cardiac catheterisation laboratory using X-ray screening, therefore if you think you may be pregnant will you please let us know before the procedure. The procedure involves inserting a fine plastic tube (referred to as a sheath) into an artery via a small puncture hole in the groin or wrist. The groin is the most favoured site of entry. This is done under local anaesthetic. Through the sheath a fine tube called a guide catheter is threaded up to the heart and positioned at the beginning of the coronary artery. A fine balloon catheter is then threaded through the guide catheter, down the artery into the narrowing. The stent is a thin metal scaffold tube. The stent is mounted on the balloon catheter. (See fig. 1) Fig. 1 Once the balloon catheter is positioned it is inflated which causes the stent to expand and be pressed up to against the wall of the artery. The balloon is then deflated and removed leaving the stent in place, keeping the artery open. (See fig. 2) BENEFITS OF THE PROCEDURE Coronary angioplasty and stenting allows a narrow or occluded artery to the heart to be treated within the vessel rather than by cardiac surgery, which involves opening the chest wall. The procedure is simpler and recovery after it is shorter than for standard coronary artery bypass surgery. Patients who have recently sustained a heart attack (Myocardial Infarction) or where other methods such as thrombolytic therapy (clot buster treatment) have been unsuccessful, angioplasty and stents can re-open the vessel. Long term survival may be improved after coronary angioplasty. Most patients experience a dramatic improvement in angina symptoms following this procedure. ON RETURN TO THE WARD An ECG (heart tracing) will be taken on your return; your nurse will check your pulse and blood pressure, and the puncture site for any complications, they will also check your foot pulses if your groin was used or the colour and warmth of your hand if your wrist was used. Usually you will be able to eat and drink on return to the ward. If the short plastic sheath was not removed immediately after the procedure it will remain in your groin until your blood clotting time (thickness of your blood) has returned to normal. Whilst this is in place you will need to remain in bed keeping your legs straight and only sitting up at a slight angle. Usually at about 4 to 6 hours following your procedure or sometimes the following day, you will have your sheath removed. When the sheath is removed, the nurse or doctor will need to press over the puncture site for about 15 to 30 minutes to ensure that the bleeding has stopped. Once this has been removed, you will need to remain on bed rest for a further 2 hours. Fig 2 (not actual size)

5 RISKS Whenever a procedure is performed particularly one involving the heart, there are risks involved. Thankfully, the risks for this procedure are small, but never the less important. There is a chance that the balloon and stent may damage the inside of the heart artery, causing it to tear or block; this may cause a heart attack. The chance of this occurring is about 1 or 2% (1-2 in 100). In about 0.3% (1 in 300) of people, they need to treat this with an emergency bypass operation. These are serious problems and we know that some people do not survive these sorts of complications, about 0.5% of all patients (1in 200). To help prevent this, medication is given to you before and during the procedure. There is a small chance about 2% (1-2 in 100) that you might develop a complication with the site of the procedure in the groin. This usually amounts to bruising which will resolve with rest. In a small number of cases a minor operation is required if a larger bruise with a collection of blood (haematoma) occurs. In the first 3 months after your procedure there is a chance that the artery may re narrow or even block, again medication like aspirin and clopidogrel will help prevent this. This occurs in about 15% of cases. As technology improves, there are newer stents which have reduced the risk of re narrowing to only about 5% of patients with even fewer needing a further stent. These new stents are called drug eluting or drug releasing stents. The radiation risk from the X-rays used during coronary angioplasty is equivalent to four years of background radiation (radiation that is normally found in the atmosphere) which is present in everyday life Several inflations and possibly more than 1 stent may be necessary to gradually widen the narrowing to achieve a satisfactory result. Once the required result has been achieved, the balloon is deflated and removed along with the guide catheter and wire, leaving a wider artery with improvement of the blood flow to the heart muscle. The stent remains in place and can not be removed or move of its own accord. Over time the stent becomes part of the artery wall. Following the insertion of a stent a thin film of cells grows over and lines the surface of the stent. This process is completed between 1 month and 6 months depending on the type of stent used. Until this time there is a risk of blood clotting which may occur on the surface of the stent and therefore block the coronary artery. This would cause you to experience chest pain and risk of a heart attack. This risk can be significantly reduced by medicines such as Aspirin and Clopidogrel. These will be explained a little later in this booklet. ON ADMISSION Many patients are seen in a pre admission clinic before being admitted to hospital for their procedure. If you are on warfarin or have diabetes the doctor and nursing staff will advise you about what tablets you may need to stop before coming in to hospital. Remember to bring all your usual medication with you to your pre admission clinic and your admission. You will be admitted to either ward 34, 28, 33 or 33a. On admission you will be informed of when you are scheduled for your procedure, which may be the following day if further blood tests or X-rays are required. If you are well after the procedure and following discussions with you, we may discharge you home the same day or ask you to remain in hospital for a night. -4-

6 PREPARATION On admission, the nurse looking after you will be able to advise you of what time you need to starve from and when you must stop drinking from. This depends on when you will be having your procedure. On the morning of your procedure your nurse will ask you to have a shower or a bath. Before coming into hospital please shave the hair in your groin about an inch at both sides, as this is where the tube is passed into the blood vessel under local anaesthetic. If you are unable or unsure about doing this, it can be done in hospital. In case medication and fluids are needed to be given during the procedure, a small plastic tube (called a venflon or cannula) will be placed in the back of your hand or arm. A gown and pants will be provided for you to wear during your procedure. About an hour before you go for your angioplasty or stent implant you may be given the opportunity to have a pre medication of either a tablet or an injection to help you relax. These are not routinely used but you can ask for this if you feel particularly anxious. The procedure is performed away from the ward in one of the catheter rooms (labs). The lab contains the specialised X-ray and monitoring equipment required for the procedure. The staff in the department wear gowns and gloves, as this is a clean procedure. DURING THE ANGIOPLASTY / STENT IMPLANT If you have previously had a cardiac catheter you will find there is really very little difference in what to expect during the procedure. bed onto the X-ray table, which is narrow, firm and moves up and down as required. Heart monitoring (ECG) leads will be attached to your arms and legs. Your groin or wrist will be cleaned by an antiseptic lotion and covered with sterile towels. A local anaesthetic will be injected to numb the skin around the area where the tube be inserted. You should feel no pain apart from the initial sting of the local anaesthetic. Once the guide wire has been passed through the artery in the groin or wrist, you will not feel it as it is passed up to your heart. With the help of a dye, X-rays and a television screen the narrowing in the artery is seen. The X-ray equipment will be brought close to your chest to allow the balloon catheter to be positioned. You will be asked to rest your arms above your head during parts of the procedure so they do not get in the way of the X-ray machine. Whilst the balloon is being inflated in the coronary artery, you may experience your usual angina symptoms which you should inform the doctor of straightaway. This is due to the balloon causing a temporary blockage of blood flow through the artery and is to be expected. The procedure may take 30 minutes or longer depending on the complexity and number of the narrowings in your coronary arteries. If more than one coronary artery requires treatment, each may be treated during the one procedure or on separate occasions. The sheath inserted in the groin or wrist to allow the catheter to be passed to the heart, will be removed at the end of the procedure. Sometimes the sheath in the groin may need to remain for a few hours after or sometimes until the following morning. Sometimes a Closure Device is used to seal the entrance hole in the artery. On arrival at the catheter room, you will be transferred from your

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