Harvard Heart Letter

Angioplasty a day after a heart attack not worth it

Medical therapy is better for late treatment.

Imagine this scenario: You've finally gone to the hospital because of chest pain you were having yesterday. After an electrocardiogram and blood test, you're told that sometime in the preceding 24 hours a clot in one of your coronary arteries cut off the blood supply to a section of your heart muscle. You had a heart attack!

So should you get an artery-opening angioplasty?

No. In 2006, the Occluded Artery Trial (OAT) determined that performing angioplasty — an invasive and expensive procedure — delivered no tangible benefit to people who'd had a heart attack more than 24 hours earlier and who no longer had symptoms.

In 2007, the American College of Cardiology and the American Heart Association endorsed the OAT findings and issued this guideline: angioplasty to unclog an artery implicated in a heart attack, when performed more than 24 hours after the event, is not appropriate as long as the person is stable.

But not all doctors and hospitals have been heeding that directive, and many people showing up "late" after a heart attack are still receiving angioplasty.

One study looked at nearly 29,000 heart attack victims treated at more than 1,000 U.S. hospitals from 2005 through 2008, all of whom underwent angioplasty more than 24 hours after having the attack. The researchers compared the number of angioplasties performed before the OAT results were published, after they were published, and after the guideline was issued. Rates of late angioplasty were virtually unchanged throughout the entire four-year period (Archives of Internal Medicine, published online July 11, 2011).

Why hasn't practice changed? Some doctors may be unfamiliar with the no-angioplasty approach in this scenario; others may not agree with it. Doctors may have concerns about being sued if they don't intervene aggressively. They may also be swayed by people's expectations of a dramatic response to a heart attack. Some studies even suggest that doctors are more likely to follow guidelines that recommend a new action rather than stopping an old one.

If you seek treatment for symptoms that turn out to be a day-old heart attack and your heart is stable at the time, you shouldn't get an angioplasty. Medical treatment should do just as good a job with a lower risk of complications. If your doctor does recommend an angioplasty in such a case, ask why — and whether he or she is aware of the guideline.

Get thee to a hospital!

Most importantly, don't wait if you think you're having a heart attack. The sooner you get treated, the less likely you'll develop heart failure later, another study has shown.

Danish researchers looked at nearly 8,000 individuals who'd had a heart attack and received angioplasty within 12 hours of the start of symptoms. The risk of developing heart failure over the next three years rose by 4% for each hour of added time between symptom onset and angioplasty (Annals of Internal Medicine, Sept. 20, 2011).

Once you enter a hospital, it's up to the professionals to avoid treatment delays. But you're responsible for preventing the first holdup. If you think you're having a heart attack, call 911. It's better to risk embarrassment if your symptoms turn out to be heartburn or to shell out an ER co-pay than to let heart muscle die and increase your odds of developing a difficult-to-manage condition like chronic heart failure.