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Prof. Dr. S. Georgiev, “The Decision on Stent Placement Should Be Made by a Team of Different Specialists”

Cardiovascular diseases are the main cause of mortality among the population in the European Union. These diseases are leading in the death rate in Bulgaria as well, and the most common cause is constriction or blockage of the coronary blood vessels in two out of three cases. The reasons for this are rooted in the way of eating and the way of life. Moreover, as we age, the incidence of damaging the circulatory system by the atherosclerotic process increases, leading to more frequent manifestation of these diseases.

Responding to the major needs of the population for timely treatment of the conditions associated with the complications of this process, a network of angiographic laboratories, more than 60, has been established in the country, resulting in a sharp decrease in the disability, associated with this pathology. A great number of them are structural units that conclude contracts with NHIF only for this type of activities. However, a great part of these units do not have multidisciplinary medical teams, which deprives patients of the possibilities of complex treatment. They provide only interventional cardiology, which takes into account neither the concomitant diseases that the patient very often has, nor the possibilities of complications, occurring after the intervention. In such angiographic laboratories only the heart is being treated, not the patient.

 "Interventional cardiology includes diagnostics of heart diseases by catheterization - inserting catheters in the heart, injecting contrast dye through the catheter, which depicts the cardiac structures, thus visualizing the inner surface of the cardiac blood vessels. These are the so-called "colorful" pictures of the heart in patients with angina pectoris or patients with heart attack," explains Prof. Dr. Svetoslav Georgiev, an interventional cardiologist at University Hospital "St. Marina" in Varna. "This also includes situations where patients have valvular heart defects - the valves are damaged, and a decision should be made whether these valves need to be operated or not. In order to decide on an operation it is necessary to make an accurate assessment of how severe the defect is; whether it damages the heart; and if the valve needs to be replaced. When a patient gets into the operating room, simultaneously with a valve change, if necessary, a bypass surgery is also performed to avoid reopening the chest," Prof. Georgiev added.

"If the patient does not have a valve defect and a stent should be placed urgently, a great part of the laboratories ignore the fact that he has other pathology as well, a problem which remains unsolved in urgent conditions. This is often the reason why the patient is seeking medical help again in 2-3 days after that, when such an intervention is performed in an angiographic laboratory. When discussing an operation at multi-profile hospitals, doctors start working on all the other diseases that should be taken into consideration.

Complications, which are an unavoidable part of invasive activities, are related to impaired kidney function, resulting in acute renal failure, and if it is not treated from the beginning, the patient often needs to go on hemodialysis. The risks of complications are also related to the possibility that the patient may bleed, and in this case he will seek medical help again outside the angiographic laboratory, where the intervention has been performed, because patients in these situations are not accepted in them. In elderly patients, such intervention is very risky because they do not suffer only from a heart disease, and a thorough comprehensive assessment is needed before the intervention. In medicine it is not possible to cure the heart in one hospital; kidneys - in another one, intestines in a third one. A comprehensive assessment is required, which can be done only at large multi-profile hospitals, which have the necessary equipment and specialists in various fields of medicine.

In recent years specialists have reported changes in the structure of cardiovascular diseases. Cardiovascular diseases have become more urgent and more common in the elderly people. Parallel with the growing average age of the population, the heart diseases become a priority among the people over the age of 55. The more the age progresses, the more the frequency increases and the urgency grows. The decision-making time is limited in these cases, and if it is incorrect, it brings the patient into a situation, where he can even lose his life afterwards, even though the blood vessel has been fixed," Prof. Georgiev says. "In Bulgaria chronic, gradually progressive forms of coronary heart diseases decrease as a relative share (e.g. angina pectoris) in comparison to acute ones, i.e. situations where urgent activities are required. The acute form of this disease is acute infarction.

Chronic illnesses are treated with medications that reduce symptoms, and patients live a quality life. Patients with angina pectoris cannot perform hard work because hard physical activities overburden the heart. When there is a constriction of the blood vessel, the blood supply to the heart itself is restricted, some of the muscle cells begin to suffer from a lack of oxygen, and the alarm in our body goes off - a pain starts, most often in the chest. The patient is forced to stop hard physical activities, and the pain subsides.

In acute forms, the constriction is already impaired because it is composed of abnormal cells that die at some point and break up the plaque, and this is a signal for the organism that there is a breakthrough in the circulatory system, and it reacts by trying to block it. How does the breakthrough get blocked? A thrombus is formed in a blood vessel, with a diameter of 4mm in its widest part, but in the more peripheral parts it is up to 3-2mm. This thrombus is formed very quickly - several cells become a magnet for the other cells, there is a total occlusion of the blood vessel within half an hour up to an hour, the supply of any oxygen and food to the cells stops, and they die progressively in an hour. Therefore, it is vital to act very quickly in these situations. Stents completely hamper the constriction and restore the normal diameter of the blood vessel, by which the blood begins to move at normal speed, and this reduces the risk of thrombus formation substantially. The stent, however, is a foreign body, and the organism tries to isolate it, the only way to do that is to accumulate the same cells that form the thrombus around it. This results in a new blood vessel occlusion within half an hour. That is why these patients take powerful combinations of anticoagulants. There are already two risks combined in patients experiencing such a problem. One of them is the thrombus formation (connected to the stent placed), and the other one - the risk of bleeding (connected to the concomitant mandatory medical treatment). If the patient has a risk of bleeding related to another non-cardiac disease - these drugs are contraindicated and, if given, they can lead to death. The fact that we have fixed the heart is absolutely worthless if we have killed the man," says Prof. Georgiev.

"The behaviour recommended by the international medical community now is before placing a foreign body in the organism, a comprehensive assessment of the risks and benefits of stenting in the specific situation to be made. The correct solution is to discuss the overall behaviour in the context of the immediate and consequent needs of the patient, which means the issues to be discussed not only with a cardiologist but also with an interventional cardiologist who places the stents, a cardio-surgeon and eventually with a neurologist, a nephrologist and a vascular surgeon, because the viewpoints are different. The team approach is crucial, and when it comes to cardiovascular diseases, it is plausible only in hospitals that have the appropriate departments - cardiac surgery, vascular surgery, nephrology, neurology and neurosurgery. In Bulgaria these are the hospitals in the university centres - Sofia, Varna, Plovdiv, Stara Zagora, Pleven.

The risks associated with interventional treatment are related to the possibility while curing the heart, another organ to be damaged, because each organ needs blood supply in order to function normally, and the vascular regions are connected to each other. Priority evaluation is the most crucial issue. The damage of cardiac vessels quite often is combined with impairment of the cerebral vessels, and that is why we make frequent simultaneous diagnostics of both vascular areas at University Hospital "St. Marina". The aim is the patient to be assessed in a comprehensive manner and treated in a complex way so that he can live longer, and not to shorten his life with a certain manipulation. There are deficiencies in the system, which provides widespread access to interventional treatment. In dozens of angiographic laboratories that have been established in very small settlements, there are two doctors, sometimes with short experience, who must be available 24 hours a day, 7 days a week. It is impossible for two doctors to take up this burden and to be in good shape for each subsequent occurring necessity. The problem of stenting is not stenting itself but the proper assessment of the specific situation, which requires both sufficient experience from the medical teams and the necessary technical equipment.

In order to change the situation in favour of patients, precise and strict control over the work of private and state angiographic laboratories is needed, an increase in the number of cardiac surgeons in the country, and proper behaviour on the part of doctors, who should treat the patient as a sick person rather than just a sick organ. We often divide the indications for performing an intervention in the human organism into clinical and anatomical. Clinical indications require a comprehensive assessment of the patient, rather than an assessment of the specific anatomy alone.

Prof. Georgiev recommends patients with symptoms to visit their general practitioner and a cardiologist at any cost, and to have their condition assessed, while in acute conditions they need to seek immediate transport to multi-profile university hospitals, which have the whole necessary arsenal for providing complex treatment.


                                                                                                                                      Velina Markovska