Angioplasty can save lives, but it isn’t always urgent. For some people, optimal medical therapy makes sense.
Each year, about 600,000 people in the United States undergo an angioplasty to widen a narrowed coronary artery, nearly always with a tiny wire mesh tube (stent) left inside the artery to keep it open. About two-thirds of these procedures are done in people experiencing a potentially life-threatening event—a heart attack or unstable angina, defined as severe, worsening chest pain during exertion or stress, or chest pain that happens at rest.
“Angioplasty is a phenomenal therapy that has greatly enhanced our ability to improve quality of life and reduce mortality in millions of people with cardiovascular disease,” says Dr. Kenneth Rosenfield, who heads the vascular medicine section at Harvard-affiliated Massachusetts General Hospital. If you have angina that suddenly worsens, angioplasty and stent placement can restore blood flow to your oxygen-starved heart, easing the pain within about 20 minutes—the average time it takes for the procedure. Once you’ve recovered, you may find you’re able to exercise longer than before. And if you’re having a heart attack, the procedure will lower your risk of a having a second heart attack or of dying.
During angioplasty, a doctor inserts a
Illustration by Scott Leighton
The remaining one-third of angioplasties, known as nonemergency or elective angioplasties, are done in people thought to be at risk of a heart attack, most often because a stress test suggests a possible blockage in one or more of the heart’s arteries. But unless a person has symptoms, an angioplasty is usually not necessary and medical therapy (including drugs and lifestyle changes) is equally effective, not to mention less expensive and less risky than angioplasty. Complications of angioplasty include bleeding at the catheter insertion site (see illustration), which in rare cases requires a blood transfusion or surgery. Blood clots that can occur during the procedure trigger a minor heart attack in less than one in 100 people, and a stroke in less than one in 300.
What to ask before an elective angioplasty
Start by asking your cardiologist to explain the evidence from your testing that suggests you need an angioplasty. Then ask:
1. Can medications address my symptoms?
2. What are the risks of the procedure?
3. Will it help me feel better?
4. Will it help me live longer?
If you have any uncertainty, consider getting a second opinion, says Dr. Gibson. If you have only mild symptoms, you can always get an angioplasty at a later time if your symptoms become troublesome.
Medical treatment options
“If an exercise stress test suggests you may have a narrowed artery but you are active and have no symptoms, an angioplasty may not reduce your risk of heart attack or help you live longer,” says Dr. C. Michael Gibson, professor of medicine at Harvard Medical School and an interventional cardiologist at Beth Israel Deaconess Medical Center. To help you decide if you should have the procedure, see “What to ask before an elective angioplasty,” at left.
Even if you experience mild angina when you exercise and your stress test reveals mild ischemia (reduced blood flow to the heart), medication is a reasonable option, says Dr. Rosenfield. Your doctor might prescribe a beta blocker to lower your heart rate and nitroglycerin to temporarily widen blood vessels.
But while a beta blocker may help you walk farther, says Dr. Rosenfield, “you might still have angina after a brisk, 15-minute walk. Then, let’s say you almost pass out after you take nitroglycerin. Technically, you have stable angina and therefore may not absolutely need an angioplasty. But even if the procedure won’t prolong your life, it may improve your quality of life,” he says.
If you fall into the uncertain category, a careful discussion with your cardiologist about the possible benefits and risks of angioplasty for your particular situation is essential.