Coronary Artery Disease Treatment in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS (PCI / CABG):

• Stable CAD with significant single-, double-, or triple-vessel disease (FFR ≤0.80 or angiographic stenosis ≥70%) refractory to optimal medical therapy

• Acute coronary syndromes (STEMI, NSTEMI, unstable angina) requiring urgent or early invasive strategy

• Left main coronary artery disease (LMCA stenosis ≥50%) — Heart Team decision between PCI and CABG based on SYNTAX Score

• SYNTAX Score ≤22: PCI is preferred for multivessel disease

• SYNTAX Score 23–32: equipoise; individualised Heart Team decision

• SYNTAX Score ≥33: CABG preferred (superior long-term outcomes demonstrated in SYNTAX, FREEDOM, and NOBLE trials)

• Patients with diabetes mellitus and multivessel CAD: CABG strongly preferred (FREEDOM trial data)

• Reduced LVEF (EF <35%) with viable myocardium on PET/MRI viability imaging indicating potential functional recovery post-revascularisation

• Silent ischaemia with objective evidence of large ischaemic burden (>10% of LV myocardium) on stress imaging

• REQUIRED DIAGNOSTIC WORKUP PRIOR TO TRAVEL:

• Resting 12-lead ECG and 24-hour Holter monitor

• Transthoracic echocardiogram (TTE/ECHO) with LVEF assessment

• Coronary CT angiography (CTCA) with or without FFR-CT (if invasive angiography not yet performed)

• Stress test: treadmill, stress echo, or myocardial perfusion SPECT/PET

• Cardiac MRI with late gadolinium enhancement for viability assessment (where LVEF is reduced)

• Full blood panel: CBC, renal function (eGFR), HbA1c, fasting lipid panel, coagulation profile (INR/aPTT), BNP/NT-proBNP

• Carotid Doppler ultrasound (mandatory pre-CABG)

• Peripheral vascular assessment if conduit harvesting (saphenous vein, radial artery) planned

• Pulmonary function tests (pre-CABG)

• CONTRAINDICATIONS / HIGH-RISK CONSIDERATIONS:

• Active systemic infection or sepsis (elective procedure must be deferred)

• Severe uncorrected coagulopathy or active major bleeding

• Contrast allergy without adequate pre-medication protocol

• eGFR <15 mL/min/1.73m² — requires nephrology optimisation and may indicate off-pump CABG preference

• Severe, irreversible non-ischaemic cardiomyopathy where revascularisation offers no benefit

• High perioperative surgical risk: EuroSCORE II >10% or STS predicted mortality >8% — requires careful Heart Team deliberation, possible alternative (TAVI paradigm-equivalent; consider TMVr if concurrent MR)

• Haemodynamic instability requiring mechanical circulatory support stabilisation prior to elective transfer

PHARMACOLOGICAL (OPTIMISED MEDICAL THERAPY — OMT):

All CAD patients receive evidence-based pharmacotherapy regardless of revascularisation strategy. Core agents include: high-intensity statins targeting LDL-C <55 mg/dL (ESC 2023 goal for very high-risk patients); PCSK9 inhibitors (evolocumab, alirocumab) for statin-intolerant or refractory hyperlipidaemia; dual antiplatelet therapy (DAPT) with aspirin 75–100 mg + ticagrelor 90 mg BD or prasugrel 10 mg OD post-ACS/PCI; beta-blockers (bisoprolol, metoprolol succinate); ACE inhibitors or sacubitril/valsartan (ARNi) for EF <40%; SGLT-2 inhibitors (empagliflozin, dapagliflozin) for cardioprotection and HF risk reduction; ranolazine or ivabradine for persistent angina on maximal therapy; colchicine 0.5 mg OD for residual inflammatory risk (LoDoCo2 evidence).

PERCUTANEOUS CORONARY INTERVENTION (PCI):

• Standard PCI: Radial-access preferred (reduced MACE and bleeding vs. femoral; MATRIX trial data); 6F or 7F guiding catheter; coronary angiography and real-time stenting under fluoroscopic guidance.

• Drug-Eluting Stents (DES): Third-generation ultrathin-strut biodegradable-polymer DES (e.g., Orsiro, XIENCE Sierra, Resolute Onyx) are the current standard, with restenosis rates <5% at 1 year.

• Intravascular Imaging-Guided PCI: Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are used routinely at partner centres to optimise stent sizing, apposition, and landing zones, reducing stent failure rates by 30–40% (ILUMIEN IV, OCTOBER trials).

• Physiology-Guided PCI: FFR (fractional flow reserve) and instantaneous wave-free ratio (iFR) used to defer stenting of non-flow-limiting lesions, reducing unnecessary procedures.

• Complex PCI Techniques: Rotational atherectomy (Rotablator) for heavily calcified lesions; orbital atherectomy; intravascular lithotripsy (IVL / Shockwave) for calcified nodules; chronic total occlusion (CTO) PCI using antegrade dissection/re-entry (ADR) and retrograde techniques — success rates >85% at high-volume centres.

• Haemodynamic Support: Impella CP/5.5 or IABP utilised for high-risk PCI (unprotected LMCA, severely reduced EF).

CORONARY ARTERY BYPASS GRAFTING (CABG):

• Conventional On-Pump CABG: Median sternotomy with cardiopulmonary bypass (CPB) and cardioplegic arrest; remains gold standard for complex multivessel and LMCA disease.

• Off-Pump CABG (OPCAB): Performed on the beating heart without CPB; reduces neurological complications and blood product use; preferred in patients with porcelain aorta, severe renal impairment, or high stroke risk.

• Minimally Invasive Direct CABG (MIDCAB): Left anterior thoracotomy approach for LIMA-to-LAD grafting in isolated LAD disease; faster recovery, no sternotomy.

• Totally Endoscopic CABG (TECAB): Robotic-assisted (da Vinci Surgical System) fully endoscopic CABG; available at select partner centres; 3–5 mm port incisions, significantly reduced recovery time and transfusion rates.

• Hybrid Coronary Revascularisation (HCR): Combines robotic MIDCAB (LIMA-LAD) with same-sitting or staged PCI to non-LAD vessels — optimal for patients who benefit from arterial LIMA grafting to the LAD but are not ideal surgical candidates for full sternotomy.

• Conduit Selection: Left internal mammary artery (LIMA) to LAD is the benchmark graft (10-year patency >90%); bilateral internal mammary arteries (BIMA) improve long-term survival but require careful selection (avoid in diabetics with poor wound healing); radial artery grafts; saphenous vein grafts (SVG) with contemporary no-touch harvesting technique improving 1-year patency.

• Total Arterial Revascularisation: Increasingly performed at GAF partner centres for younger patients (<65 years) to maximise graft longevity.

HYBRID AND STRUCTURAL INTERVENTIONS FOR CO-EXISTING PATHOLOGY:

• Transcatheter Aortic Valve Replacement (TAVR/TAVI): When CAD coexists with severe aortic stenosis; concomitant or staged PCI + TAVI performed.

• MitraClip / Transcatheter Mitral Valve Repair (TMVr): For ischaemic mitral regurgitation associated with CAD and reduced EF.

• Renal Denervation: Considered adjunctively in CAD patients with resistant hypertension.

• Enhanced External Counterpulsation (EECP): Non-invasive option for refractory angina in patients who are not revascularisation candidates; 35-session outpatient protocol.

PHASE 1 — PRE-TRAVEL CONSULTATION (Weeks 1–2 before departure):

• GAF Healthcare coordinates a teleconsultation with the assigned interventional cardiologist or cardiac surgeon at the chosen partner centre.

• All diagnostic records (angiogram images/DICOM files, ECHO report, stress test, blood work) are reviewed remotely.

• A preliminary treatment plan — PCI vs. CABG vs. OMT — is confirmed by the multidisciplinary Heart Team.

• Patient receives a personalised cost estimate, visa assistance, pre-travel medication guidance (antiplatelet continuation/bridging instructions), and travel insurance advisory.

• GAF secures the hospital admission slot and arranges airport reception.

PHASE 2 — ARRIVAL AND PRE-PROCEDURE ASSESSMENT (Days 1–2):

• Airport pickup by GAF-assigned medical concierge; transfer to partner hospital or pre-booked accommodation.

• Repeat baseline investigations on arrival: ECG, ECHO, renal panel, coagulation screen, CBC, chest X-ray.

• Anaesthesiology and cardiac surgical pre-operative evaluation (for CABG candidates).

• Invasive coronary angiography performed (if not done pre-travel) to finalise anatomy and SYNTAX Score.

• Heart Team meeting (where applicable) to confirm revascularisation strategy.

• Informed consent obtained; anaesthesia plan documented; NPO instructions given.

PHASE 3 — THE PROCEDURE:

• PCI (Duration: 45–90 minutes): Radial artery access; real-time coronary angiography; IVUS/OCT imaging; stent deployment with post-dilatation; haemostasis with radial compression band; patient transferred to cardiac care unit (CCU) for 12–24 hours monitoring.

• CABG (Duration: 3–6 hours): General anaesthesia induction; median sternotomy or minimally invasive/robotic access; conduit harvesting; anastomosis construction; CPB weaning (if on-pump); chest closure; ICU admission for 24–48 hours intensive haemodynamic monitoring.

PHASE 4 — IN-HOSPITAL RECOVERY:

• PCI: CCU monitoring for 12–24 hours; radial site assessment; ambulation on Day 1; DAPT education; discharge typically Day 2–3 post-procedure.

• CABG: ICU 24–48 hours → step-down cardiac ward; physiotherapy begins Day 2 (deep breathing exercises, early ambulation); chest drains removed Day 2–3; temporary pacing wires removed Day 4–5; sternum stability and wound assessment; discharge Day 5–7.

• All patients: Repeat ECHO before discharge; medication reconciliation; cardiologist discharge summary provided.

PHASE 5 — POST-DISCHARGE RECOVERY AND FIT-TO-FLY ASSESSMENT:

• PCI patients: 7–10 days local rest recommended; outpatient cardiology review at Day 10–14; ECG and wound check; fit-to-fly assessment at 2–3 weeks post-PCI; compression stockings and DVT prophylaxis guidance for long-haul flight.

• CABG patients: 2–3 weeks local convalescence at GAF-arranged serviced accommodation; cardiac rehabilitation sessions begin Day 7–10 (supervised by partner centre physiotherapist); repeat ECHO and wound review at Week 3; sternal precautions (no lifting >5 kg, no driving) for 6 weeks; fit-to-fly typically at 4–6 weeks post-CABG subject to cardiologist clearance and absence of pleural effusion or wound complication.

• GAF Healthcare provides a detailed Fit-to-Fly certificate and a structured home-country handover document for the patient's local cardiologist.

PHASE 6 — LONG-TERM FOLLOW-UP:

• GAF coordinates remote follow-up teleconsultation at 1 month, 3 months, and 6 months post-discharge.

• Statin, antiplatelet, and GDMT adherence monitoring via GAF digital health platform.

• Annual stress imaging or CTCA to monitor graft patency (post-CABG) or in-stent restenosis (post-PCI).