Coronary artery disease Q&A with Dr Iftikhar Fazal

Dr Iftikhar Fazal is a Consultant Cardiologist at BMI The Park Hospital.

We caught up with Dr Iftikhar Fazal to ask him a few questions about coronary artery disease, covering what the main causes are and how to manage it.

Dr Fazal is a general cardiologist with a sub-specialist interest in heart failure, pacing, and rhythm abnormalities. 

He's also performed procedures including, pacemaker implantation, ICD implantation and cardiac catheterisation.

Coronary artery disease should be considered in patients complaining of chest discomfort/pain, exertional breathlessness, or exercise intolerance. The cardiologist will take a detailed history, including family history, risk factors for coronary disease, and undertake an examination of your heart and usually do an ECG.

Further specific tests may be required including blood tests, an echocardiogram, stress testing (exercise tests, stress echocardiogram, myocardial perfusion scans), and CT calcium scores +/- CT coronary angiograms. A coronary angiogram (or cardiac catheterisation) may be recommended if the likelihood of you having coronary artery disease is high, or to help plan specific treatment.

Coronary artery disease is caused by fatty deposits (atheroma) in the walls of the coronary arteries. These fatty deposits are made up of cholesterol and other substances. Over time, the fatty deposits can cause narrowing of the coronary arteries which reduces blood flow and results in angina.

The fatty deposits can also ‘rupture’ causing a complete blockage of the coronary artery, resulting in a heart attack. Risk factors for developing coronary artery disease are:

  • Smoking
  • High blood pressure
  • High cholesterol
  • Diabetes
  • Family history
  • Being overweight
  • Lack of regular exercise

Coronary artery disease is managed by a combination of lifestyle changes, medication, and revascularisation including:

  • Stopping smoking 
  • Healthy eating
  • Weight loss
  • Regular exercise
  • Reducing salt intake
  • Moderating alcohol intake

Medications include blood thinning medications such as Aspirin, statins to reduce cholesterol, beta blockers, nitrates/GTN spray and blood pressure tablets such as, ACE inhibitors. More specific treatments to improve the blood supply such as, stents and heart bypass surgery may be needed.

Coronary artery disease may be treated by percutaneous coronary intervention (PCI/stents) or coronary artery bypass grafting (CABG). PCI (or angioplasty) involves inserting a balloon over a wire into the coronary artery, inflating it to reduce the narrowing and then implanting a stent to keep the coronary artery open. A stent is a small mesh like structure that can be expanded to keep the artery from collapsing again after the balloon inflation.

CABG may be required if there is severe narrowing in the coronary arteries in multiple places and/or if the narrowing is in an important place, particularly if you also have diabetes and heart failure. 

The blood vessel (vein or artery) is grafted onto the aorta and then to the coronary artery beyond the narrowing, thus bypassing the narrowing. Blood vessels can be harvested from the veins in the legs or from the wall of the chest and used as grafts to bypass the narrowing in the coronary arteries. Often, more than one bypass graft is required, hence the terms triple bypass and quadruple bypass.

I was always interested in the medical specialties at medical school and in my early training as a junior doctor. Cardiology is unique amongst the medical specialties in so far as there is a substantial craft/procedural aspect to many of the treatments that we offer and is thus more of a surgical specialty.

There is an extensive evidence base with multiple large scale randomised controlled trials looking into the effectiveness of various medications and treatments. It also offers the ability to diagnose particular problems with the heart through the use of focused history taking and logical investigations and all of these aspects attracted me to cardiology.

Cardiology is now a very specialised field; my main subspecialty is heart failure & pacing but I have been thoroughly trained in most aspects of general cardiology and keep up-to-date with general cardiology. There have been significant advances in the management of heart failure and rhythm abnormalities over the last few years which have led to improved survival and reduction in sudden cardiac death from heart rhythm problems. This particular aspect confirmed my initial choice of cardiology as a specialty but also heart failure, pacing, and rhythm abnormalities as my specialist area.

BMI The Park provides a range of cardiology services and facilities including implantation of pacemakers, implantation of defibrillators and a new cardiac cath lab.