Voyage through heart arteries in patients of heart attack -Landmark study by Prof (Dr) Upendra Kaul

Prof.(Dr.) Upendra Kaul, Chairman Cardiology and Executive Director and Dean at Batra Hospital and Medical Research centre, New Delhi & course director at India Live 2018 has been conducting several landmark projects at Batra Hospital and Medical Research Centre. One of his recent study is on vessel wall visualization after a recent heart attack. It is in fact a voyage thru heart arteries in patients of heart attack.

This is an investigator-initiated project which will be conducted at 10 centers in India and 100 patients will be included in the study. The study is called ACS-OCT India study. The study aims to see the plaques (deposits on arteries, which are made up of fats, cholesterol, calcium and other substances in the blood) characteristics in young Indian patients (<45 yrs. of age) who had a recent heart attack (Acute Coronary Syndrome, ACS). Heart Attack is caused by sudden blockage of one of the 3 arteries supplying blood to the heart (Culprit Artery). The special interest of the study is to study the arteries not actually producing the heart attack (Non-Culprit Artery).

The basis of this study is the assumption that ACS is an inflammatory disease and could involve all the arteries to some extent. The degree of inflammation in other arteries could have a bearing on the long-term prognosis of the patient. In addition, optimal medical treatment consisting of blood thinners (Aspirin-like drugs), cholesterol-lowering drugs (statins) and other agents to control the risk factors like high BP, Diabetes, smoking etc. should influence by reducing the inflammation and tendency to block the arteries by preventing clot formation. Visualization of the interior of these arteries during the acute phase and follow up would, therefore, be of interest in prognosticating and deciding regarding the intensity of drug treatment and need for angioplasty.

Some of these non-culprit vessels would be having blocks of intermediate severity in addition to signs of inflammation, erosion and plaque rupture etc. Whether to do angioplasty or stenting in these patients is another challenging area?

Routine angiography has limitations in answering several of these issues. Modern technology based upon the assessment of physiology and studying the morphology of the wall of these arteries should be able to guide the cardiologist in managing these problems. Two of the technologies currently in vogue to answer these issues are:

1 Optical Coherence Tomography (OCT)

2.Fractional flow Reserve measurement (FFR)

Optical Coherence Tomography (OCT) is an established imaging technique which uses light to capture three-dimensional images. It provides tomographic images markedly superior to that provided by any other currently available imaging technique. The superior quality of the images makes it possible to better determine the health of the blood vessels and helps to take better treatment decisions and study the characteristics of plaques, erosions, and clots. If the diseased artery needs to be subjected to angioplasty and stenting, the images taken after the procedure ensure complete coverage of the vessel wall by the stent struts. An incomplete coverage can lead to problems like stent clotting or thrombosis.

Fractional flow Reserve(FFR)measurement;

This is a method to evaluate the functional assessment of an intermediate or borderline lesion. It essentially measures the pressure difference across the blockade at maximal flow which is induced by injecting a drug called adenosine. A ratio < 0.80 means that the blockade is significant and needs stenting otherwise it can be left alone. Thus it acts as the third umpire of modern day cricket.

In our study, we will be using both these methods in the non-culprit vessels and base our treatment based upon the results. We will follow these patients for several years and perform a repeat OCT and FFR after one year in all.

The project is being handled by the Academics and Research team of BHMRC which includes protocol development, selection of principal investigators, and training of research team, project management and eventual publications. All the OCT images recorded at various centers will be analyzed by a dedicated Core Lab team at Batra Hospital & Medical Research Centre.

Prof Upendra Kaul is Chairman Cardiology and Executive Director and Dean at the Batra Hospital and Medical Research centre, New Delhi and a course director at India Live 2018. He was formerly an Executive Director and Dean at the Fortis Health Care and a professor of Cardiology at the AIIMS.