Not as much as you might think, unless you are having a heart
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
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").
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
medications to control cholesterol, blood pressure,
and blood sugar
a healthier diet
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.
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
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.