Coronary angioplasty is a technical marvel. A thin tube is threaded from an artery in the groin to the heart. Through this tube a tiny balloon is threaded into a narrowed coronary artery. The balloon is inflated to open the artery, and then a stent (a metal mesh tube) is placed in the newly open artery to keep it open. About a million coronary angioplasties are done in the United States annually.
The procedure was initially developed with the hopes that opening narrow arteries would prevent heart attacks and save lives in people with chronic coronary disease (narrowing of the coronary arteries). Alas, that’s not the case. Every study that has compared angioplasty to optimal treatment with medications has found no difference in the rates of heart attack and death between the two. The largest such study was published in April of last year.
This was a major disappointment for proponents of angioplasty. Angioplasty is a proven life-saver and is the treatment of choice in acute heart attacks, so it was hoped that it would also be life-saving in people at high risk for a heart attack with chronic coronary disease.
Part of the problem is the remarkable improvements in medical treatment of heart disease. Optimal medical treatment now includes a cholesterol-lowering medicine in the statin family, aspirin, a beta blocker and an ACE inhibitor (two different families of blood pressure medicines). Each of these families of medicines has been proven to prevent heart attacks. The outlook for patients on this regimen is so good that it’s difficult for a new proposed treatment to do even better.
The proponents of angioplasty then argued that though angioplasty may not be life-saving, it helps quality of life by eradicating chest pain in patients with chronic heart disease. A follow up study published this week in the New England Journal of Medicine examined that assertion. It randomized patients with chronic heart disease to angioplasty with optimal medications or optimal medications alone, and followed the quality of life and the amount of chest pain in both groups.
The good news is that both groups steadily improved and did well overall. The patients who had angioplasty had less chest pain about a year after angioplasty, but that difference disappeared by three years after randomization.
The bottom line is that angioplasty should be reserved for patients having an acute heart attack or for patients with chronic chest pain whose symptoms are not well controlled on optimal medications.
Associated Press article: Drugs as good as stents for many heart patients
The New England Journal of Medicine article in 2007 demonstrating that angioplasty does not save lives or prevent heart attacks: Optimal Medical Therapy with or without PCI for Stable Coronary Disease
This week’s New England Journal of Medicine article: Effect of PCI on Quality of Life in Patients with Stable Coronary Disease