Harvard Heart Letter

What can angioplasty do for you?

Not as much as you might think, unless you are having a heart attack.

If bypass surgery is a marvel of modern medicine, then angioplasty is a double marvel. It restores healthy blood flow to oxygen-starved heart muscle without opening the chest, splitting apart the breastbone, and stopping the heart.

The problem with marvels is that we come to expect too much from them. That has happened with angioplasty. Many people think of it as a cure for heart disease, but it really isn't. When done to ease chest pain from angina, angioplasty plus a stent is more like taking ibuprofen for a fever. It eases symptoms but doesn't address the real problem — the artery-clogging process known as atherosclerosis.

An eye-opening paper in Annals of Internal Medicine highlights the disconnect between what elective angioplasty can do and what people expect from it.

Immediate but limited benefit

Stable angina occurs when one or more coronary arteries — the blood vessels that nourish heart muscle — become narrowed by the growth of fatty plaque. Narrowed vessels deliver enough oxygen-rich blood to satisfy the needs of the heart at rest. But they can't open enough to carry extra blood when heart muscle demands more oxygen, such as during physical activity, stress, or anger. The lack of oxygen produces angina — pain, pressure, or discomfort in or around the chest.

Angioplasty plus stenting is an excellent way to open narrowed arteries. A doctor inserts a thin tube called a catheter into a blood vessel in the groin and carefully maneuvers it into the clogged artery on the outer surface of the heart. Once the tube is in place, a tiny balloon at its tip is quickly inflated and deflated. This flattens the cholesterol-filled plaque that's blocking blood flow. A wire-mesh stent is usually left behind to prop open the artery.

The procedure generally takes a couple of hours and requires an overnight stay in the hospital. Recovery time is short. Angina usually improves quickly, and the effect lasts for a few years.

But the benefits stop there. Angioplasty for stable angina does not halt the spread of atherosclerosis and the damage it causes. It doesn't reduce the chances of having a future heart attack or improve survival. For these long-term benefits, you need aggressive medical therapy — heart-protecting drugs and lifestyle interventions (see "Take COURAGE").

Take COURAGE

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial set out to answer a simple question: which is better — medical therapy (using drugs and lifestyle changes) alone or medical therapy plus angioplasty and a stent — for treating a narrowed coronary artery that is causing stable angina or no problems at all?

The surprise winner was medical therapy alone. A key lesson from COURAGE: stable angina or a narrowed coronary artery that doesn't cause any problems isn't a ticking time bomb that must be fixed right away, especially if you feel fine. You can take the time to choose how best to treat it.

Drug therapy and lifestyle changes appear to be the best medicine. They protect all of your arteries, not just the one in the most obvious trouble. Attacking atherosclerosis on all fronts usually includes

  • medications to control angina, such as a long-acting nitrate plus a beta blocker or calcium-channel blocker

  • medications to control cholesterol, blood pressure, and blood sugar

  • more exercise

  • a healthier diet

  • stress control

  • smoking cessation if you smoke.

If, after six months to a year, angina is still bothering you or keeping you from doing activities you enjoy, angioplasty or bypass surgery are reasonable next steps.

One more caveat: angioplasty by itself does nothing for a narrowed coronary artery that isn't causing any problems. Why not? If you aren't having any symptoms, the procedure can't relieve any. It doesn't protect you from having a heart attack or dying prematurely from heart disease. And it may lull you into a false sense of security that you have taken care of the problem, when in reality atherosclerosis continues to slowly corrode other arteries in your heart and elsewhere. In other words, you get no benefit, but face some risks.

Angioplasty is generally safe and effective, but not complication-free. Some people have prolonged bleeding from the site in the groin through which the angioplasty catheter is inserted into the femoral artery. The dye used to illuminate coronary arteries can harm the kidneys. Angioplasty can set off an abnormal heart rhythm or trigger a heart attack or stroke. Mind you, these problems aren't common. Nationwide, angioplasty causes a problem for about five people out of every 100 — the number is lower at large centers where angioplasty is done many times a day, and higher in centers where it is done less often. Complications aside, getting a newer drug-coated stent means you must take aspirin and clopidogrel (Plavix) for at least a year.

Disconnect

At Baystate Medical Center in Springfield, Mass., researchers interviewed 153 men and women who were planning to undergo elective angioplasty. Only 40% were having the procedure to alleviate chest pain that limited their activities. The rest had mild angina or symptomless narrowings discovered on an exercise stress test. In other words, 60% of the people having angioplasty would have been better off with intensive medical and lifestyle therapy (Annals of Internal Medicine, Sept. 7, 2010).

Even more distressing, a whopping 88% said they believed that the procedure would help protect them from having a heart attack down the road. Although most of their doctors didn't believe that, the disconnect between patients' beliefs or expectations and what angioplasty could really do for them suggests that doctors don't always take the time to explain the actual benefits and risks of the procedure or succeed in communicating them.

Heart attack is a different story

If you are having a heart attack or an episode of unstable angina, angioplasty is a terrific treatment. Both of these all-too-common problems are caused by a completely blocked coronary artery. Angioplasty and stenting removes the obstruction, allowing blood to once again reach all parts of the heart, and props open the artery. Timely angioplasty can limit heart muscle damage and prevent a heart attack from turning into a deadly cardiac arrest. For a heart attack or unstable angina, angioplasty is definitely better than drug treatment at preventing a second heart attack and improving long-term survival.

Clearer expectations

One reason people have high hopes for angioplasty is confusion over what it can do. If you are having a heart attack, angioplasty is a marvelous procedure. But if you have angina now and then, or a narrowed coronary artery that isn't causing you any trouble at all, angioplasty adds little or nothing to intensive drug therapy and lifestyle changes.

It is easy to put your faith in what seems like a simple procedure to fix a narrowed or clogged coronary artery. But it is better to invest the time and energy to fight the disease that is causing the problem.