10 things I didn’t know about angioplasty until I read this book

by Carolyn Thomas    ♥  @HeartSisters

Being asked to write a book review is tricky. Authors hope you will be kind, while you hope the book at best might tell you something that every other book for heart patients hasn’t already told you. A review copy of the book Your Personal Guide: Angioplasty (Allen Jeremias, Susan S. Bartell)*  sat on my coffee table for weeks, until one day, I finally got tired of looking at this latest addition to my living room decor and decided to give it a go.   And within a very few pages, I learned some fascinating things I didn’t know before.  

These included:

1.  It’s possible to have significant coronary artery disease (CAD) with multiple blockages greater than 70% yet have no symptoms of angina on exertion, especially in people who are sedentary (because they often don’t exert themselves enough to challenge their heart muscle).

2.  Heart attacks are usually triggered by unstable coronary artery blockages of less than 70% which don’t cause any symptoms. In fact, only 20-30% of heart attacks occur at the site of an artery that’s more than 70% blocked. If you have one blocked artery causing you chest pain and other cardiac symptoms, it is virtually certain that this is merely the tip of the iceberg.

3.  When you have a blockage in a coronary artery, Emergency Department staff may administer clot-busting drugs, especially if your hospital isn’t equipped to perform invasive procedures like angioplasty or bypass surgery to help re-open that artery. Clot busters, however, have only a 50-60% success rate.

4. The word “stent” comes from its creator, Charles Stent (1807-1885), an English dentist who invented a compound to produce dentures and other things like skin grafts and hollow tubes (essentially what a metal coronary stent is).  His real claim to fame occurred when he suggested using his material to coat underwater trans-Atlantic cable, which had broken several times as a result of corrosion by seawater.

5.  Most coronary stents start out as a solid, hollow tube.  The openings (a lattice-like chicken wire effect) are then created with laser cuts, although some stents are braided from individual thin metal wires. It’s a design intended to keep the stent flexible enough to navigate the twists and turns of our coronary arteries on its way up to the heart.

6.  The air pressure in your fully inflated car tires is about 2 atmospheres. By comparison, the high pressure used to inflate a balloon inside a coronary artery during angioplasty is between 10-20 atmospheres.  NOTE FROM CAROLYN: this helps to explain the common experience of distressing post-stent chest pain following this procedure.

7.  Angioplasty is not generally recommended for blockages below 70%. There is no proven benefit in implanting a stent in a blockage that does not impair blood flow to the heart muscle. These blockages generally require medications and lifestyle changes to treat successfully.

8.  There is no cure for the chronic condition called coronary artery disease (CAD). Once plaque has built up in your arteries, it is very difficult to eliminate. Embracing a healthy lifestyle can help control CAD, but remember that the word “control” here means “stopping the progression of the disease”.

9.  If you have a significant coronary artery blockage (more than 70% blocked) , it’s a red flag that more blockages can happen at any time in the future.  In fact, once a critical blockage like this is identified, it means you already have plaque buildup and minor blockages in many, many arteries of your heart that can significantly increase your chances of having a heart attack.

10. Up to 30% of those who have had stents implanted or open heart bypass surgery still experience ongoing angina afterwards.

This book is co-written by psychologist Dr. Susan Bartell and cardiologist Dr. Allen Jeremias. The format is loosely based on the varied experiences and 36 questions of five fictional but true-to-life heart patients: Brian, Michael, Diane, Rosa and Reginald. It may seem like a clever idea, but does mean that useful information may not be as accessible as it would be in a more logically-organized format.  You essentially have to read the entire book cover to cover to make sure you catch all references to each important topic.

Many patients, however, use heart books (or Dr. Google) to look up the answer to the most important question they may have at any particular moment. The good news: the book is an easy read; you’ll likely have little trouble reading it straight through.

Responses to each of the questions posed by the five fictional patients are generally those typical of people facing angioplasty (although do so many of them have to be smokers?) Answers to the questions are divided into two sections:

• The Bottom Line (basic important information)
• The Nitty Gritty (additional info in more detail)

While the book’s 248 pages go into impressive detail for any patients who have already undergone (or are scheduled for) angioplasty procedures, there remain at least two unfortunate omissions.

Omission #1. I was dismayed to discover that, despite the fact that one of the book’s co-authors (Dr. Bartell) is a psychologist, the psychosocial impact of being diagnosed with heart disease is virtually ignored.

In fact, I could find only one reference to mental health issues that are common among so many heart patients, but that one reference is buried in a single paragraph in the “What About Sex?” section about halfway through the book:

“Aside from receiving medical clearance to engage in sexual activity, it is important to note that many individuals with coronary artery disease experience anxiety or depression as a result of the diagnosis. These feelings often come from being confronted with a life-or-death situation (especially after a heart attack).  These strong emotional responses (especially depression) can contribute to decreased sexual desire or a reduced ability to perform sexually.”

But narrowly limiting this too-brief overview to the sex chapter unfortunately dismisses critically important issues that can be so damaging to overall health recovery following a cardiac event. (Mayo Clinic cardiologists, for example,  estimate that up to 65% of newly diagnosed heart patients experience depression, yet fewer than 10% of these cases are appropriately identified).

Failure to discuss mental health is a serious gap in a book that includes, for instance, page after page of exercise recommendations for those diagnosed with coronary artery disease.

Yet we know that one of the inevitable consequences experienced by heart patients who are suffering from depression, anxiety or any type of psychological distress is a severely impaired ability to follow the exercise, diet, medication or lifestyle improvement advice  recommended here. 

I’m not a psychologist, but I have written more about heart disease and mental health issues on this one little blog than this book from two experts even begins to cover.

I also included an entire chapter on situational depression in heart patients in my book “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press, 2017). You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 20% off the list price).

Readers keen to learn more about coping with these psychosocial issues known to be associated with a diagnosis of heart disease won’t find that help here, but would do well to instead seek out Dr. Wayne Sotile‘s very useful book called Thriving With Heart Disease. (That whole book focuses on the psychological impact of a cardiac diagnosis on both patients and their family members).

Omission #2. I may have missed this, but the second glaring omission in the angioplasty book was this: no mention of patients who survive heart attacks caused by Spontaneous Coronary Artery Dissection (SCAD).  No longer considered a rare disease, this often deadly diagnosis typically strikes young, healthy females with few if any cardiac risk factors. It’s now more correctly thought to be an under-diagnosed disease (not rare!) – and thus needs to be included in any book that covers angioplasty, particularly since angioplasty was until recently commonly attempted on SCAD patients before newer research revealed significant risks in doing so. 

UPDATE:   Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic and chair of the 2018 American Heart Association committee that wrote “Spontaneous Coronary Artery Dissection: Current State of the Science”, reported that, unlike its standard use in opening up blocked coronary arteries in non-SCAD heart attack patients, angioplasty for the treatment of SCAD heart attacks is “associated with an increased risk of complications.”(1)   Mayo Clinic has also pioneered important SCAD research trials.

I’d love to see these two omissions addressed in future editions of an otherwise excellent basic resource for heart patients undergoing angioplasty and those who care about them.

I’d also love to see the content reorganized, sorted into content-specific sections that make sense, not focusing on the five fictional patients so patients don’t have to work hard to find info that should be much easier to access.

This book does a solid job of clearly describing cardiac diagnostic tests, angioplasty and other invasive cardiac procedure options, risk factors and heart disease symptoms – all helpfully illustrated throughout with easy-to-understand drawings.

It would be especially useful to worried patients who are scheduled for angioplasty at some point in the near future,  and who want a comprehensive overview to help them prepare.

For these reasons, it deserves a home in my collection of heart books.

Please note: information on this website or in the book being reviewed here is not intended to replace medical advice.  Consult your physician for questions about your own personal health.

* Your Personal Guide: Angioplasty by Allen Jeremias, M.D. and Susan S. Bartell, Psy.D.  – MPP Publishing 2012.

1. Hayes, Sharonne N et al. “Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association.” Circulation vol. 137,19 (2018): e523-e557.

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Q: Do you have a favourite heart book? Tell us about it. 

See also:

When an illness narrative isn’t just about illness

A Woman’s Guide to Living with Heart Disease: My blog-turned-book project

The new country called Heart Disease

Women’s heart pain is both physical and emotional

The chest pain of angina comes in four flavours

‘Time equals muscle’ during women’s heart attacks

Squishing, burning and implanting your heart troubles away

“I’m not depressed!” – and other ways we deny the stigma of mental illness after a heart attack

Depressing news about depression and women’s heart disease

10 non-drug ways to treat depression in heart patients

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