Triple Vessel Disease

Introduction

Heart disease is one of the leading global causes of death.¹ Coronary artery disease (CAD)  is a serious cardiovascular disease characterized by the buildup of plaque and fats in the blood vessels within the heart. CAD can lead to further cardiovascular complications including heart attack, stroke, and heart failure.²  Some patients may display a more serious form of the disease known as Triple Vessel Disease. A triple vessel disease is an advanced form of coronary artery disease that is characterized by blockage of the heart’s three main vessels.^2,3 It is a life-threatening disease that requires immediate medical attention and treatment to ensure patient survival. 

What is Triple Vessel Disease?

​​Triple vessel disease, also known as multivessel coronary artery disease, is a blockage of all three of the main coronary vessels.¹ This blockage is caused by the deposition of fats in the arterial walls in a process known as atherosclerosis.² It is the most severe form of coronary artery disease and leads to several further health complications such as hypertension, stroke, and heart failure.³ Occlusion of the three coronary vessels reduces the arterial wall diameter causing reduced blood volume delivery to the heart. Insufficient blood delivery to the heart causes decreased oxygen and nutrient delivery which causes gradual strain on the heart’s function.^3,4 

Prevalence

In 2019, coronary artery disease was the global cause of mortality, and it remains one of the leading contributors to mortality.⁵ According to the British Health Foundation, men are more likely to die from coronary artery disease than women. Coronary artery disease prevalence increases as women and men age; coronary artery disease also kills more UK women than other serious diseases such as breast cancer.⁶ In the past two decades, CVD cases in Europe have increased, however, prevalence does vary between European regions. As Triple vessel disease is a specific and severe coronary artery disease form, there is quite a lack of statistics on the condition’s prevalence and mortality. However, physiological studies and statistical analysis have both proven that triple vessel disease patients have a higher mortality risk than coronary artery disease patients.⁷ According to a Mayo Clinic study, 45%-85% of men with angina have triple vessel disease.⁸ 

Causes/Risk Factors

Coronary artery disease is caused by the accumulation of fats and plaques in the walls of the arteries surrounding the heart.⁴ Fat accumulation causes a progressive reduction in the arterial wall diameter leading to the decreased blood volume capacity of the arteries and thus decreased blood flow, oxygen, and nutrient delivery to the heart.⁴  In triple vessel disease specifically, three of the heart’s main arteries progressively occlude leading to a significantly greater reduction in blood flow, oxygen delivery, and nutrient delivery to the heart.¹ As a result, triple vessel disease may even present as more pronounced than coronary artery disease due to the greater severity of its symptoms.

There are several risk factors associated with atherosclerosis (fat accumulation), development, and progression to coronary artery disease:  

Smoking: Smoking tobacco is considered a major risk factor for coronary artery syndrome as nicotine and carbon monoxide from cigarettes cause the heart to work harder than normal (leading to inexertion). Several chemicals within cigarettes may damage the arterial lining of coronary vessels which also contributes to the gradual progressive changes in arterial structure.⁸ 

High blood pressure: High blood pressure is a significant risk factor for coronary artery disease and triple vessel disease. High blood pressure of the heart’s blood vessels can cause the blood vessels to harden, narrow, and stiffen leading to decreased blood flow to the heart.⁸ 

Gender: Several studies have shown that men have a higher risk of coronary artery disease while also developing it earlier than women. According to the British Heart Foundation, the UK, mortality risk in men is 1 in 8, and in women, it is 1 in 15. Women are generally considered to have slight biological protection against cardiovascular disease.⁹ These sex differences may be explained by the different hormone levels between men and women.^10-12

Age: All forms of cardiovascular disease are typically anywhere between seven to ten years later than men, despite it being a major cause of death in women. The risk  of coronary artery disease also increases as individuals age.¹⁰ 

Menopause: The menopause transition is characterized by a worsening of coronary artery disease risk.¹⁰ 

High cholesterol: When your cholesterol gets too high, like fat, it will accumulate on the walls of the heart’s arteries leading to atherosclerosis occurrence. High cholesterol can lead to triple vessel disease development as the main three coronary arteries may become blocked by cholesterol and/or fat deposits.¹⁰ 

Symptoms

Angina: Angina is the most significant symptom of coronary artery disease and subtypes. It may be described as a feeling of pain, pressure, heaviness, breathlessness,  pins and- needles on the chest.⁴ However, angina pain can also radiate to the arms, jaw, and stomach depending on what area of the heart the blocked artery is located. As the coronary arteries become blocked, it leads to a reduction of blood flow and thus reduced oxygen and nutrient delivery to the heart. The reduced oxygen in the heart causes the characteristic chest pain of angina.⁴ Anginal attacks can occur during stressful situations or while participating in physically strenuous tasks. Angina at rest is also a sign of triple vessel disease.  

Heart Attack: Myocardial infarction, commonly known as a heart attack, is both a complication and symptom of coronary artery disease. When one of the heart’s arteries becomes fully blocked it increases the risk of a heart attack.⁴ A heart attack occurs when the heart’s blood supply is blocked due to a blockage in one of its vessels. As blood vessels progressively occlude in coronary artery disease, they reduce the heart’s blood flow.⁴ When coronary artery disease is not diagnosed early it can lead to heart attack development. Heart attack should be considered a symptom of advanced coronary artery diseases like triple vessel disease.⁴ 

Heart Failure: Patients with coronary artery disease are also at increased risk of heart failure. Heart failure occurs when the heart starts to fail at performing functions due to its weakened state.⁴ In coronary artery disease patients, heart failure may occur following a heart attack. The heart damage sustained from a heart attack occurrence may further weaken the heart leading to heart failure. However, heart failure can also occur as the vessels become occluded the reduced nutrient and oxygen delivery can cause the heart to have a poorer function as it lacks the necessary nutrients and oxygen to sustain its activity.⁴ 

Diagnosis

Medical professionals can use several diagnosis methods to diagnose coronary artery disease and triple vessel disease.

Electrocardiogram

Electrocardiogram: Electrocardiogram, also commonly known as ECG or EKG is a diagnostic test that is used to measure the heart’s electrical activity, heart rate, and the consistency of the heartbeat.⁴ With each heartbeat, the ECG machine produces small electrical pulses that it records on paper to generate an ECG chart for doctor interpretation. It is a painless, non-invasive diagnostic method that typically takes only five minutes to perform. It is useful as it can help a medical team conclude where the blocked arteries may be based on the abnormal appearance of some of the ECG waves on the chart.⁴ 

Echocardiogram

​​Echocardiogram: Echocardiogram is an ultrasound test that creates a visualization of the heart and its arteries for diagnosis. An echocardiogram involves using a small probe to emit sound waves to create echoes that spread to different parts of the heart.¹² A probe then picks up the echoes and converts them into a moving image on a computer monitor as the echocardiogram is being performed. Echocardiograms are essentially similar to pregnancy ultrasounds but specifically for the heart. Echocardiograms can be used to detect areas of heart damage and occluded arteries for diagnosis of coronary artery disease and triple vessel disease.¹² 

Stress test

Stress Test: An exercise stress test, also known as exercise ECG or exercise tolerance test is another type of electrocardiogram test in which the heart’s function during physical exertion is tested.¹³ Stress tests help with coronary artery disease and triple vessel disease diagnosis as it concludes if the heart muscle receives adequate blood flow during exercise. It can also be used to diagnose exercise-induced angina (stable angina) and angina at rest (unstable angina), which also mark the severity of coronary artery disease.

Cardiac catheterisation and angiogram

CT coronary angiogram is a procedure in which the heart’s structure and function are examined for diagnosis of coronary artery disease.¹⁴ In this diagnostic procedure, X-rays of the heart’s arteries are taken using an invasive technique called coronary angiography. In the procedure, a flexible and thin tube called a catheter is placed in either the arm or groin. X-ray images then help a doctor guide the catheter’s tip through the heart and its arteries. A dye called a contrast medium is injected into the catheters and X-ray images known as angiograms are taken. The procedure is undergone when the patient is under local anaesthetic for minimal pain. This procedure is good for the initial diagnosis of coronary artery disease, and planning of surgery to find which specific arteries are blocked.¹⁴ 

CT coronary angiogram

CT (Computerised tomography) angiogram is a procedure that depicts the flow of blood through the blood vessels of the heart.¹⁵ It is less invasive than a cardiac catheterisation and angiogram test. The patient lies on a bed that is passed through a CT scanner to show detailed images of the heart’s structure. A dye is then injected via a small vein in the patient’s arm. CT angiogram is not as accurate at detecting structural abnormalities in smaller blood vessels compared to cardiac catheterization and angiogram.¹⁵ This procedure diagnoses triple vessel disease and aids doctors in determining a treatment plan based on what the tests found.

Treatment

Coronary artery bypass graft (CABG)

The coronary artery bypass graft is a surgical treatment option for patients with triple vessel disease. The procedure consists of doctors taking a blood vessel from one area of the body such as the arm, chest, or leg and surgically attaching it to the coronary artery and below the narrowed area or the occluded area.¹⁶ The graft refers to the new blood vessel. The number of grafts made depends on the severity of the disease and the number of blocked heart vessels. Patients with triple vessel disease may require three or more grafts due to the blockage in three main arteries (16). Patients undergoing a coronary artery bypass graft will be under a general anaesthetic so that they are unconscious throughout the procedure; the procedure typically lasts between 3 to 6 hours.¹⁶ Following the procedure, patients may stay up to eight days in the hospital. Most patients can recover 12 weeks following surgery, but it usually takes over six weeks to return to performing everyday activities such as working and driving.¹⁶ 

Coronary artery bypass graft surgery is only a treatment for triple vessel disease rather than a cure. Lifestyle changes must be made to prevent the narrowing and hardening of the grafts.

How long can you live with triple vessel disease?

Due to the severity of the condition, patients with triple vessel disease have a worse prognosis and chance of survival than patients with non-advanced coronary artery disease. As there is no cure, prolonging life expectancy largely depends on the prevention of disease progress and treatment. In most cardiovascular conditions, life expectancy typically decreases the patient’s expected life expectancy by between 8% and 10%.¹⁷ However, if a patient succumbs to complications such as a heart attack, heart failure, and stroke, life expectancy can decrease even more substantially. According to a 2009 study, most risk facers are associated with a 10-to-15-year reduction in life expectancy after the age of 50.¹⁸ Ultimately, life expectancy depends on the severity and advancement of the disease, the patient’s age, and clinical symptom presentation.¹⁸ 

Conclusion

Triple vessel disease is the most severe form of coronary artery disease that is characterized by at least 50% narrowing of the three main arteries of the heart. Coronary artery disease remains a leading global cause of mortality; it is also a substantial problem in Europe, but the prevalence varies per region. Triple vessel disease is caused by the accumulation of lipids and cholesterol in the arterial walls of the heart. Risk factors like smoking, high fat, and cholesterol diet both initiate and progress the disease. Non-modifiable risk factors such as age, gender, and menopause also alter the presentation and advancement of the disease. Triple vessel disease can lead to heart attack occurrence, heart failure, and stroke due to insufficient oxygen and nutrient flow to the heart. There are various diagnostic methods used by doctors to diagnose and determine treatment methods. Coronary artery bypass graft surgery is the most commonly used treatment method. Although there is no cure for triple vessel disease, one can still live a healthy and normal life with the disease by reducing risk factors and making healthy life choices.