Is that angioplasty really necessary?

Content provided by the Faculty of the Harvard Medical School

Is that angioplasty really necessary?

In the throes of a heart attack, artery-opening angioplasty is a lifesaver. The same can't be said when it's done to open a narrowed heart artery that isn't causing problems.

A quarter of a century ago, Andreas Grüntzig wheeled a colleague with chest pain into a Zurich operating room for a procedure that hadn't been tried before on a human. The Swiss cardiologist guided a balloon-tipped wire into his friend's diseased coronary artery, nestled it in a narrowing that restricted blood flow, and inflated the balloon. Like blasting open a dam, the balloon pushed aside the artery-narrowing plaque and allowed blood to once again flow freely through the artery.

Many cardiologists thought this was a harebrained scheme for restoring blood flow through narrowed or blocked coronary arteries. They were wrong. Today, more than two million people (600,000 of them Americans) undergo balloon angioplasty each year. Some angioplasties are done to stop a heart attack, others to relieve severe chest pain. And some aren't absolutely necessary, or necessarily the right thing to do.

If you are contemplating angioplasty to ease modest angina, or because you have one or more narrowed arteries, it's a good bet the procedure will open the problematic vessel(s). But you also need to know that it doesn't do anything to halt atherosclerosis, the disease that caused the problem. It won't lengthen your life or protect you from a heart attack. For that you need to attack the atherosclerosis itself.

Advantages of angioplasty

Balloon angioplasty has become one of the three standard treatments (with bypass surgery and drug therapy) for coronary artery disease. In this common condition, cholesterol-filled plaque bulges into the channel available for blood flow in one or more of the arteries that nourish the heart muscle. Such narrowings are exceedingly common. They often go unnoticed. They are also what cause angina, the chest pain that predictably occurs with exercise, exertion, or stress.

Angioplasty offers an easy alternative to bypass surgery. There's no need to split open the chest or stop the heart. Instead of spending several days in the hospital and a few weeks recovering, most people spend one night in the hospital and are back to their normal routine in just a few days.

In fact, angioplasty is easy enough to do that it is sometimes done too often.

No chest pain, no gain?

A growing number of angioplasties arise from this all-too-common scenario: Say you are worried about heart disease or you've been having some pain in your chest or arm. So you schedule a heart scan, or your doctor suggests an exercise stress test "just to be on the safe side," even though the symptoms probably aren't heart-related.

If the result is abnormal, the next step is usually a coronary angiogram, a special x-ray that reveals the blood vessels that nourish the heart. When a narrowed artery appears on the angiogram, as it so often does, many cardiologists recommend opening it and holding it open with a wire mesh stent. You agree — who wants to be walking around with a narrowed coronary artery? — and go home after the procedure feeling like you've been saved from a certain heart attack.

You probably haven't. In this scenario, angio­plasty is no better than standard drug therapy at protecting you against a heart attack and carries small but real risks of causing a heart attack or problem requiring emergency surgery.

The use of angioplasty for opening partially blocked arteries that haven't been causing any symptoms has been questioned for some time. An analysis of 11 trials that pitted angioplasty against standard medical therapy supports this concern. Among almost 3,000 participants, half of whom received angioplasty and half standard medical therapy, the numbers of deaths, heart attacks, and follow-up angioplasties or bypass surgeries were nearly the same in both groups. The results were published in the June 7, 2005, Circulation.

Another, more recent study had similar results. The large, well-done study presented at the American College of Cardiology meeting held in March 2007 found that in people with stable coronary disease—that is, people who have chest pain with exertion but not at rest—angioplasty with stenting was no better than taking medication and modifying their lifestyles. In the study, more than 2,000 people with stable coronary disease were treated with medications and counseled on a healthy lifestyle for heart disease. Half of the people also got angioplasty and stenting. At the end of five years, the groups had similar rates of heart attack and death. People in the stenting group reported less chest pain at the three-year mark, but the groups were equal in this regard at the end of five years.

How can this be? Angioplasty crushes the enemy — fatty plaque — and a stent props open the artery. Why wouldn't this have a grand payoff?

The answer is that there are more enemies than just the targeted spot. For every big, bulging plaque visible on an angiogram, dozens of others line your coronary arteries. Large plaques are just as likely to bulge inward as outward, so some aren't detectable on an angiogram. These "hidden" plaques are just as likely as the obvious ones to burst and cause a blood clot, the event that kicks off a heart attack.

Opening an artery In an angioplasty, a thin catheter is maneuvered to the site of the blockage (A). A thin, flexible guide wire is then advanced through the narrowing, followed by the balloon and stent (B). Inflating the balloon pushes aside the plaque and expands the stent, which holds the artery open (C).

Don't leave it alone

If you are having a heart attack and get to the hospital quickly, angioplasty followed by placement of a stent is the best option for opening the totally blocked artery that's causing the trouble. It saves lives, curtails damage to heart muscle, and relieves chest pain.

Angioplasty is also a good call if you have bothersome angina. It won't protect you against a future heart attack, but it can ease your symptoms and help you live a normal, active life.

How about if you have a narrowed coronary artery but feel fine — no pain or pressure in your chest when you exert yourself, no shortness of breath or lightheadedness? Angioplasty fixes what looks like the plumbing problem, but it won't help you live longer. It won't protect you from a heart attack. And since you feel fine, it can't make you feel better, at least not physically, though it might give you some psychological relief.

In this situation, it's best to go after all your plaques, not just the biggest one. That's easier said than done, of course. Atherosclerosis is a persistent foe. You fight it with lifestyle changes and drug therapy. Exercise, a healthier diet, not smoking, and stress reduction help control blood pressure, cholesterol, and inflammation, and make all your blood vessels healthier. Drug therapy supports and extends these efforts. Common anti-atherosclerosis medications include aspirin, a statin, and medications for blood pressure and other heart disease risk factors.

If you decide that angioplasty is right for you even if you aren't having chest pain or other symptoms, don't be lulled into thinking that it will cure your cardiovascular problem. That takes the hard work of lifestyle changes and medical therapy.

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Last updated:	May 02, 2007