Research finds that angioplasty is used on those who may not need it
Each year, more than a million angioplasty proceduresalso called percutaneous coronary interventions, or PCIsare performed in the United States to open narrowed or clogged arteries. Used chiefly to treat acute coronary syndromes such as heart attacks and the severe cardiac-related chest pain known as unstable angina, an emergency angioplasty can be a life-saving procedure that restores blood flow to the heart and reduces heart muscle damage.
During angioplasty, a catheter with a balloon at its tip is directed through a puncture into an artery in the leg or arm to the site where a coronary artery is narrowed by plaques. The balloon is inflated to compress the plaques against the artery wall, stretch the artery and improve blood flow to the heart. A stent, which resembles a wire mesh tube, is usually inserted into the artery during angioplasty to help keep the vessel open.
Doctors also use angioplasties in non-life-threatening situationsprimarily to ease symptoms of stable angina (chest pain that occurs with exertion) and improve quality of life (lasting for up to three years). But drug therapy can be just as effectivean outcome that was first established by the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) clinical trial in 2007.
The trial showed that, in patients with stable angina, drug therapy with angioplasty had no better outcome than drug therapy without angioplasty. In 2009, the American College of Cardiology, the American Heart Association and several other medical societies established criteria to assist cardiologists when they consider coronary revascularization procedures like angioplasty and coronary artery bypass graft (CABG) surgery that restore blood flow to the heart.
The criteria favor drug therapy over angioplasty as the first-line treatment approach for stable angina. But it seems that some cardiologists are straying from these suggested medical protocols.
Too many elective angioplasties
According to a study published online in the Journal of the American College of Cardiology in May 2012, one in seven non-emergency angioplasties may be inappropriate and unlikely to improve patients' health or survival outcomes.
For the study, a team of researchers from several prominent medical institutions, including Johns Hopkins, investigated whether cardiologists were following established criteria when they chose candidates for angioplasty and CABG. Unlike angioplasty, CABG is an invasive open-heart surgical procedure that uses a blood vessel from the chest or a portion of a vein from the leg to channel blood around a narrowed segment of a coronary artery.
Doctors typically use CABG for severe coronary heart disease, such as when there are several blockages in one artery, blockages in several arteries, a narrowing of the heart's left main coronary artery or poor function of the heart's lower left chamber. CABG is also preferred over angioplasty for people with diabetes, who tend to fare better with bypass surgery.
The research team reviewed medical records of 32,713 patients who underwent elective angioplasty and CABG in New York hospitals in 2009 and 2010. None of the patients had acute coronary syndrome or a previous CABG surgery. Nearly all non-emergency CABG surgeries90.3 percentmet the procedure's appropriateness criteria.
On the other hand, researchers found a low rate of appropriate angioplasty procedures. Of the 24,545 angioplasties rated:
- 14.3 percent didn't meet the procedure's criteria and provided no clear benefit
- 49.6 percent were of uncertain benefit since available data lacked enough evidence to establish whether proper criteria were followed
- 36.1 percent clearly met the criteria
The criteria classify angioplasties as inappropriate for several reasons, such as when used for patients with no symptoms, little or no prior medical therapy or low-risk heart disease. The rates for inappropriate procedures varied from hospital to hospital, with some hospitals at 1 percent and others as high as 40 percent.
Other studies involving appropriate-use criteria have reached much the same conclusion. In 2011, a larger study in the Journal of the American Medical Association had similar results, reporting that only half of angioplasties performed in a non-emergency setting were clearly appropriate.
Twelve percent were considered inappropriate, and 38 percent were of uncertain benefit. Hospital variations for inappropriate procedures ranged from 6 percent to nearly 17 percent.
James L. Weiss, MD, Michael J. Cudahy Professor of Cardiology, Johns Hopkins University School of Medicine
It bodes well to try drug therapy first for uncomplicated stable angina. Some patients don't want to wait to see whether drugs will improve their symptoms over time.
Also, patients may not distinguish between stable and unstable angina because both produce chest pain, which people tend to associate with a heart attack. But if you have stable angina, you should know angioplasty won't put you at any less risk for a heart attack than you were before the procedure. And even if you have an angioplasty, drug therapy will be a necessary part of managing your angina afterward.
Source: Prepared by the Editors of The Johns Hopkins Medical Letter: Health After 50