Contrary to what many people think, elective angioplasty doesn't reduce the chances of future heart attacks or extend life expectancy. What may contribute to patients' confusion is that angioplasties do reduce the risk of heart attack and death in patients with acute coronary syndromes.
Even so, many stable angina patients believe that angioplasty will lengthen their lives or reduce heart attack risks and insist on the procedure even when noninvasive drug therapy might serve them just as well or better. This belief, and the willingness of some cardiologists to perform the procedure to allay patient fears, could partly explain the reason for some inappropriate angioplasties.
Another reason angioplasties are overused may be the convenience of performing the procedure immediately after an angiographythe traditional test used to determine the extent of heart disease. Also known as cardiac catheterization, angiography involves threading a catheter through an artery from an incision in the groin or arm to the heart to find blockages. Combining the procedures if a blockage is found may be preferred by doctors and patients, who can avoid a second procedure if drug therapy isn't successful.
In fact, many patients about to undergo an angiography are asked to sign a consent form to allow the cardiologist to immediately perform an angioplasty if the severity and extent of disease warrants one.
Who are the best candidates for elective angioplasty?
Experts suggest angioplasty is appropriate for stable angina patients who:
- Have undergone drug therapy but still have persistent, intolerable chest pain
- Can't tolerate aggressive drug therapy
- Are at high risk for a heart attack or death because of severe plaque buildup
Angioplasty complications are rare but can include bleeding and discomfort at the incision site and, in less than 1 percent of patients, total closure of the artery due to a blood clot, spasm or tear in a vessel wall, which can cause a major heart attack or require emergency bypass surgery.
Also, studies have shown that restenosisthe re-narrowing of the arteryoccurs about six months after angioplasty in 30 percent of patients who didn't have a stent inserted, 15 percent of patients who received a bare metal stent and less than 10 percent of people who had a drug-eluting stent (which releases medication to further prevent arteries from reclosing).
Furthermore, patients who receive drug-eluting stents are required to take the blood thinner clopidogrel, along with aspirin, for at least a year after the procedure.
The noninvasive option for managing stable angina is medication that can reduce the heart’s workload, improve blood flow and improve a diseased artery's health. Chronic stable angina is typically treated with one or more drugs such as beta-blockers, nitrates, calcium-channel blockers, ranolazine (Ranexa), antiplatelets like aspirin or clopidogrel, and statins.
Lifestyle changesquitting smoking, eating a healthy diet, increasing physical activity, reducing stress and achieving and maintaining a healthy weightcan make medications more effective.
Deciding on treatment
If you have moderate coronary disease with stable angina and are not at high risk of a heart attack, angioplasty may not be your best first-line treatment option. If your doctor suggests angioplasty, ask why he or she isn't recommending drug therapy first.
If you agree to a diagnostic angiography, discuss an elective angioplasty's benefits and drawbacks well in advance of the test. And don't be afraid to speak up and ask questions if you have any concerns about whether you really need an angioplasty.
Source: Prepared by the Editors of The Johns Hopkins Medical Letter: Health After 50