What is Multivessel Disease?

A coronary artery is like a three-layered tube. The inner layer, called the tunica intima, is covered with endothelial cells which are in direct contact with the blood flowing through the artery. These cells help maintain a balance in the artery’s functioning. A disruption in this balance can lead to a disease called atherosclerosis. Multivessel disease refers to the condition when major coronary arteries (of a certain size or larger) narrow down significantly more than 70%. Approximately 40% to 50% of patients suffering from ST-elevation myocardial infarction (STEMI), a severe heart attack, have multivessel coronary disease.

Coronary artery bypass grafting (CABG) is a surgical procedure used since 1968 mainly to restore normal blood flow to an area of the heart blocked by a clot or by buildup of fatty material within the coronary arteries. On the other hand, percutaneous intervention (PCI) was introduced in 1977 and was initially a treatment option for patients whose disease was limited to a single vessel. However, developments in heart and chest surgical methods and improved after-surgery care have decreased health complications and deaths from surgery, making CABG the preferred approach for treating multivessel disease. Over the years, advancements in PCI have also expanded its use to include treating patients with multivessel disease. Ultimately, the choice of treatment should be an interprofessional decision taking into consideration different factors, like patient preference, surgical risk, and operator skills.

What Causes Multivessel Disease?

The conditions that can make you more likely to develop blocked arteries (atherosclerosis) and coronary artery disease (CAD) include:

High blood pressure (hypertension)
High levels of fats in the blood (hyperlipidemia)
Sugar disease (diabetes mellitus)
Cigarette smoking
Age
Menopause
High levels of a certain amino acid in the blood (hyperhomocysteinemia)
Family history of CAD
Changes in a certain gene responsible for producing a protein that helps in widening blood vessels (endothelial nitric oxide synthase mutations)

When it comes to heart attacks, it’s not just plaque that breaks off and forms a blood clot that is problematic. Coronary constriction, which means the narrowing of the blood vessels of the heart, plays a significant role as well.

When it comes to CAD, women have a tougher time than men. Despite generally being less likely to have CAD, if they do get it, they often have a worse outcome.

Risk Factors and Frequency for Multivessel Disease

In simpler terms, coronary artery disease (CAD) – a heart problem – is the leading cause of death in industrialized countries. In the United States, around 16.8 million people have CAD, and 8 million of them have experienced a prior myocardial infarction, also known as a heart attack.

In 2005, it was recorded that CAD was responsible for around 607,000 deaths and it’s predicted that by 2030, this number will increase to 23.4 million. CAD not only places a heavy economic burden on the healthcare system due to the cost of treatments, but it can also lead to a significant decrease in productivity from the people it affects.

The overall cost of CAD, including direct medical costs and the costs related to reduced productivity, is estimated to be $165.4 billion in the US.

Signs and Symptoms of Multivessel Disease

When people have multivessel disease, their symptoms can vary. This variation is due to factors like how severe the disease is, the person’s other health problems which can affect how the disease presents, and how fast the disease is progressing. Typically, those with stable multivessel disease might feel chest pain or shortness of breath when they exert themselves physically. They might also feel the pain radiating to their left arm and neck.

The chest pain from multivessel disease is called “typical” if three of these signs are present:

Chest pain worsened by emotional upset or physical stress
Chest pain that is eased by resting and taking nitroglycerin
Pain, discomfort, or pressure in the middle of the chest

If only two of those signs are present, the chest pain is called “atypical”. Other discomforts that may come with the chest pain are nausea, heavy sweating, and feeling lightheaded. Some people, particularly older women and those with diabetes, may experience unusual symptoms such as discomfort in the upper abdomen and accompanying nausea and vomiting.

Acute thrombosis, another case of multivessel disease, often presents as intense, crushing chest pain in the central part of the chest, that doesn’t go away with resting but may be temporarily eased with nitroglycerin. In all cases of chest pain, it’s very important to check if the cause might be a heart attack (acute myocardial infarction), as this is an urgent, potentially life-saving situation that requires immediate medical attention.

Testing for Multivessel Disease

The possibility of a person having Coronary Artery Disease (CAD), a condition where blood vessels supplying the heart muscle become narrowed or blocked, can be estimated based on factors like their age, gender, and type of chest pain experienced. This initial estimate is called the ‘pretest probability’.

A high pretest probability, defined as over 75% or 90% chance of having CAD, means that the doctor should start treatments for CAD right away. If these treatments don’t help, the condition worsens, or the symptoms heavily affect the patient’s daily life, a test called coronary angiography, an X-ray that shows blood flow in the heart, might be needed.

Intermediate pretest probability, which is anywhere between a 10% and 90% chance of having CAD, will require the doctor to consider more factors. Other health tests like an EKG, a test that checks your heart’s activity, may be done. Depending on the patient’s ability to exercise and the results of the EKG, different types of stress tests could be performed. These tests make your heart work hard so that the doctors can see how it functions under stress. If the results are seriously concerning, a coronary angiography may be performed.

If there’s a low pretest probability, less than 25% or 10% chance of having CAD, the doctors may not require additional tests.

It’s important to note that heart imaging tests in women can be tricky and may have inaccurate results, likely caused by breast tissue interference and smaller heart ventricles, or chambers. A carotid ultrasound, a test using sound waves to create pictures of the carotid arteries to find blockages or build-up of plaque which could cause a stroke, can be used to examine for atherosclerosis. This condition involves the hardening and narrowing of the arteries which could lead to heart diseases and stroke.

Treatment Options for Multivessel Disease

In cases of a type of heart attack known as non-ST-elevation myocardial infarction (NSTEMI) or a heart condition known as unstable angina, recent studies have found no significant difference in treatment outcomes when comparing revascularization (a procedure to restore blood flow to the heart) with optimal medical therapy (the best combination of medications and lifestyle changes). If you have stable coronary artery disease (CAD), a condition that involves the narrowing of the blood vessels that supply the heart, the main aim of revascularization is to relieve symptoms, improve quality of life, and better your ability to exercise.

If you have multi-vessel disease, meaning more than one blood vessel supplying the heart is affected, the best treatment approach generally involves making significant lifestyle changes along with medicinal therapy. These changes include quitting smoking, limiting alcohol intake to less than two drinks for men and one for women, regular exercise, reducing salt intake, and losing weight. Medication often starts with aspirin, which can help prevent further heart or brain-related events, including strokes. Medications such as Beta-blockers and Calcium channel blockers can help manage chest pain, also known as angina, and statins can help manage your cholesterol levels, which have been shown to improve survival rates. Managing underlying conditions like diabetes with good blood sugar control and high blood pressure can further reduce risk.

According to the FAME1 trial, patients with multi-vessel disease who underwent routine measurement of the blood flow in the heart during their PCI (a procedure to open up narrowed or blocked blood vessels) had better outcomes at 1 year compared to patients whose PCI was guided just by conventional angiogram (an imaging technique for visualizing blood vessels). They also found preventive angioplasty (a procedure to widen narrowed or obstructed arteries or veins), used in patients with multivessel disease, could improve outcomes. Thus, based on similar findings in other trials, the current guidelines on the treatment of multivessel disease have been updated.

An analysis of large trials comparing PCI with balloon angioplasty (a procedure that widens your blood vessels) and or the use of bare-metal stents (small mesh tubes that are used to treat narrow or weak arteries) against CABG (a type of heart surgery) showed similar mortality (death) rates. Another extensive study involving over 11,000 patients comparing PCI and CABG found similar results, although in a subgroup of patients with diabetes, those who had CABG had better survival rates.

The SYNTAX trial, a study comparing outcomes between patients who underwent CABG or PCI in patients with left main coronary disease or three-vessel disease (types of more severe coronary artery disease), found that patients in the PCI group required additional treatment to restore blood flow to the heart. Therefore, based on this and other studies, surgery is generally preferred in patients with complex disease involving multiple vessels, while PCI might be reasonable in patients with less complex disease.

The reasons for typical or unexpected chest pain can vary greatly. Here are some conditions a doctor would need to consider in their diagnosis:

Stomach/Digestive issues:

Gastroesophageal reflux disease (GERD)
Discomfort during digestion (Dyspepsia)
Difficulty swallowing (Dysphagia)
Pancreatitis or inflammation of the pancreas

Heart problems:

Heart attack (Acute myocardial infarction)
Unstable and stable angina (chest pain due to reduced blood flow to heart)
Inflammation of the lining of the heart (Acute pericarditis)
Tear in the body’s main artery (Aortic dissection)
Prinzmetal angina (a type of chest pain caused by spasms in your heart’s arteries)
Drug use, like cocaine or amphetamines that can harm the heart

Issues with muscles or bones:

Rib fracture
Chronic pain syndromes
Costochondritis (pain in the chest wall and ribs)
Trauma-like injuries

Lung-related concerns:

Pleurisy (inflammation of the tissues that line the lungs and chest cavity)
Acute pulmonary embolism (a blood clot in the lungs)
Pneumonia (lung infection)
Pulmonary contusion (a bruise of the lung)
Pneumothorax (collapsed lung)

Each of these can contribute to chest pain, and a doctor would need to examine and test a patient carefully to figure out the actual underlying cause.

What to expect with Multivessel Disease

The SYNTAX trial was a major study that compared the outcomes of patients who had different types of heart surgeries. In this study, patients either had Coronary Artery Bypass Graft (CABG, a type of open-heart surgery), or Percutaneous Coronary Intervention (PCI) with a placement of a Drug-Eluting Stent (DES), which is a much less invasive procedure where a tiny wire mesh tube coated with medication is placed in a blocked artery to help keep it open.

Researchers followed up with the patients at different intervals: one year, three years, five years, and even 10 years after their procedures. Ten years later, they observed that patients with a condition known as “triple vessel disease” (when all three major heart arteries are diseased) and who underwent PCI with a DES had a 1.41 times higher chance of death compared to those who had CABG.

However, it’s important to note that the study had a few drawbacks. The biggest one being that it used first-generation paclitaxel-eluting stents (a specific type of medication-coated stent) and non-medicated stents called bare-metal stents. Newer stents coated with a drug called everolimus have been found to reduce the risk of death, heart attacks, and stent-related blood clots than these older models.

In a different study where they looked at patients with multiple diseased vessels, both the procedures – PCI with the newer everolimus stent and CABG – had a similar risk of death over a 2.9-year period. The chance of death was just slightly higher at 1.04 times for those who had PCI with a stent.

Possible Complications When Diagnosed with Multivessel Disease

When you have multivessel disease, it means you have blocked or narrowed blood vessels in many areas of your body. This can lead to a range of complications including:

Acute coronary syndrome, which includes unstable angina and types of heart attack
Restenosis or re-narrowing within a stent
Thrombosis or clotting inside a stent
Embolization or the movement of the stent from its original position
Side branch occlusion or blockage of a ‘side’ blood vessel
Stent fracture or breaking of the stent
Graft failure where a surgically implanted vessel becomes blocked

There are also various surgical complications that can occur. These include:

Bleeding
Wound dehiscence, a situation where a surgical wound re-opens
Infection
Lung complications
Stroke
Heart attack
Arrhythmia or irregular heartbeat
Acute kidney injury
Transfusion-related reactions or side effects related to blood transfusions.

Additionally, there could be complications from performing a PCI (Percutaneous Coronary Intervention), a procedure to open blocked or narrowed arteries in your heart. The potential complications can involve

Bleeding
Pseudoaneurysm, a false aneurysm
Retroperitoneal hematoma, a collection of blood in the area behind the abdominal wall
Infection
Arterial dissection, which is a small tear in the artery
Distal arterial embolization, or blockage of blood flow in a distant part of the artery
Coronary perforation, a hole in the heart artery
Stroke
Acute kidney injury
Reperfusion injury, damage caused when blood supply returns to the tissue after a period of ischemia or lack of oxygen.

Preventing Multivessel Disease

Quit smoking. This is an important step as it has great benefits in improving your health. It is also recommended to stick to your prescribed medication and exercise regimen, as well as consistently visit your doctor for check-ups.

Eating healthily and taking statin medications, which are drugs that can help control your cholesterol levels, is also vital. For those with diabetes, maintaining blood sugar levels with a target HbA1c (a measure of long-term blood sugar control) of less than 7% can be really beneficial. However, if you have other serious health conditions or tend to experience low blood sugar (hypoglycemia), your doctor might set a higher HbA1c goal for you.

Your blood pressure should also be monitored outside of the doctor’s office. The goal is to have a systolic (the top number in a blood pressure reading, indicating the force of blood against artery walls when the heart beats) pressure of less than 130 mmHg, and a diastolic (the bottom number, representing pressure in the arteries when the heart is at rest) pressure of less than 80 mmHg.

Reducing weight can also play a vital role in managing your health. A team of health professionals, such as doctors, nurses, and dietitians, can work together to help manage your condition and coordinate your care. This is known as interprofessional involvement and it can greatly help in promoting overall well-being.

Frequently asked questions

Multivessel disease refers to the condition when major coronary arteries (of a certain size or larger) narrow down significantly more than 70%.

The text does not provide information about the commonality of multivessel disease.

The signs and symptoms of Multivessel Disease include: - Chest pain or discomfort, which may be described as a pressure or heaviness in the middle of the chest. - Chest pain that worsens with emotional upset or physical stress. - Chest pain that is relieved by resting and taking nitroglycerin. - Pain or discomfort that radiates to the left arm and neck. - Nausea and vomiting, particularly in older women and those with diabetes. - Heavy sweating. - Feeling lightheaded. - Intense, crushing chest pain in the central part of the chest, which may be a sign of acute thrombosis. - It is important to note that if chest pain is present, it is crucial to rule out a heart attack (acute myocardial infarction) as this requires immediate medical attention.

The text does not provide information on how to get Multivessel Disease.

The doctor needs to rule out the following conditions when diagnosing Multivessel Disease: - Gastroesophageal reflux disease (GERD) - Discomfort during digestion (Dyspepsia) - Difficulty swallowing (Dysphagia) - Pancreatitis or inflammation of the pancreas - Heart attack (Acute myocardial infarction) - Unstable and stable angina (chest pain due to reduced blood flow to heart) - Inflammation of the lining of the heart (Acute pericarditis) - Tear in the body's main artery (Aortic dissection) - Prinzmetal angina (a type of chest pain caused by spasms in your heart's arteries) - Drug use, like cocaine or amphetamines that can harm the heart - Rib fracture - Chronic pain syndromes - Costochondritis (pain in the chest wall and ribs) - Trauma-like injuries - Pleurisy (inflammation of the tissues that line the lungs and chest cavity) - Acute pulmonary embolism (a blood clot in the lungs) - Pneumonia (lung infection) - Pulmonary contusion (a bruise of the lung) - Pneumothorax (collapsed lung)

For Multivessel Disease, the following tests may be needed: - Routine measurement of blood flow in the heart during PCI - Preventive angioplasty - Coronary angiography - Stress tests (depending on the patient's ability to exercise and the results of the EKG) - Carotid ultrasound (to examine for atherosclerosis) - EKG (to check the heart's activity) - Heart imaging tests (although they may be tricky and have inaccurate results in women)

Multivessel disease is typically treated with a combination of lifestyle changes and medication. Lifestyle changes include quitting smoking, limiting alcohol intake, regular exercise, reducing salt intake, and losing weight. Medications such as aspirin, beta-blockers, calcium channel blockers, and statins are commonly used to manage symptoms and improve outcomes. In some cases, routine measurement of blood flow during a procedure called percutaneous coronary intervention (PCI) and preventive angioplasty may be recommended. Surgery, known as coronary artery bypass grafting (CABG), is generally preferred for patients with complex disease involving multiple vessels, while PCI may be reasonable for patients with less complex disease.

The side effects when treating Multivessel Disease can include: - Acute coronary syndrome, which includes unstable angina and types of heart attack - Restenosis or re-narrowing within a stent - Thrombosis or clotting inside a stent - Embolization or the movement of the stent from its original position - Side branch occlusion or blockage of a 'side' blood vessel - Stent fracture or breaking of the stent - Graft failure where a surgically implanted vessel becomes blocked - Bleeding - Wound dehiscence, a situation where a surgical wound re-opens - Infection - Lung complications - Stroke - Heart attack - Arrhythmia or irregular heartbeat - Acute kidney injury - Transfusion-related reactions or side effects related to blood transfusions - Pseudoaneurysm, a false aneurysm - Retroperitoneal hematoma, a collection of blood in the area behind the abdominal wall - Arterial dissection, which is a small tear in the artery - Distal arterial embolization, or blockage of blood flow in a distant part of the artery - Coronary perforation, a hole in the heart artery - Reperfusion injury, damage caused when blood supply returns to the tissue after a period of ischemia or lack of oxygen.

The prognosis for Multivessel Disease can vary depending on the treatment approach. In a study comparing patients with triple vessel disease, those who underwent Percutaneous Coronary Intervention (PCI) with a Drug-Eluting Stent (DES) had a 1.41 times higher chance of death compared to those who had Coronary Artery Bypass Graft (CABG) surgery. However, newer stents coated with a drug called everolimus have been found to reduce the risk of death, heart attacks, and stent-related blood clots compared to older models. In another study, both PCI with the newer everolimus stent and CABG had a similar risk of death over a 2.9-year period.

A cardiologist.

'Percutaneous Coronary Intervention Bypass Cardiac Surgery Coronary Artery Disease Heart Health