• What's Best for the Patient With Blocked Arteries: Drugs, Stents, or Surgery?

     
     
     
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    Date: 10/28/2007

    If you have coronary artery disease, you have a blockage in your heart arteries that could cause you chest pain and even lead to a heart attack.

    While it is a serious disease, it is also one for which there are a variety of safe and effective treatments that give you a range of treatment options. For instance, a number of fortunate patients might get better simply by making lifestyle changes, such as eating better, exercising more, and taking small numbers of medications. For most others, it will likely take more intensive medical therapy, ranging from a medication-only regimen, a combination of angioplasty and stenting along with medication, or open-heart surgery along with medications, to achieve your best health outcome. In some instances, treatment may involve a combination of these approaches.

    Determining the best treatment depends on your condition, your goals for your health and lifestyle, and your assessment of the risks and benefits of each therapy. Since weighing your options can be confusing, it’s important for you to consult a doctor who is an expert in this area.

    One of the options you may be considering is a non-surgical procedure called angioplasty and stenting—angioplasty opens up the blockages so that your blood can flow easily through your arteries—which almost always provides relief from the characteristic chest pain, shortness of breath, and coronary artery disease–related fatigue. Your newly reopened arteries are kept open or “propped up” with stents that are essentially tiny little scaffolds. In this case, you would want to consult an interventional cardiologist, who performs these procedures.

    How will I know if a stent is right for me? Sometimes the choice is clear -- and urgent. If you are having a heart attack, angioplasty and stenting is almost universally believed to be the best option because it stops heart attacks. If your primary care physician or cardiologist are not available, emergency personnel who are typically involved in transporting you to the hospital will usually know that you are having a heart attack and then the course of action is undisputed: get the patient to the “cath lab” (the special catheter labs located inside the hospital where angioplasty and stenting is conducted) to stop the heart attack.

    But other times, you have time to learn about your options. For instance, if you are a sicker patient with what is called "unstable angina," you may need to choose between angioplasty and stenting or a surgery called a coronary artery bypass graft surgery also known as CABG (pronounced “cabbage”). While angioplasty and stenting is a non-surgical procedure with a quicker recovery time, it may pose a slightly higher chance you will need a repeat procedure. With surgery, it is somewhat less likely that you will need a repeat surgery in the short term, but you also face a longer recovery time, a slightly higher chance of stroke, as well as the general risks associated with major surgery (such as higher risk of infection-related complications, anesthesia-related risk, etc.).

    But what if my heart disease is characterized as “stable”? Which therapy you, as a relatively healthy, stable coronary artery disease patient, choose may also depend on your lifestyle desires. For patients able to achieve good results with a healthier lifestyle and medications, staying the course and monitoring your disease is a good option. But many patients whose condition is described as “stable” may be dissatisfied or concerned by the continued pain and limitations imposed upon them by their disease. They want to resume an active lifestyle, whether it’s working at their normal pace, walking around the block, playing with children or grandchildren, or hiking or biking in the great outdoors. These patients often find this disease particularly frustrating or frightening because, while it may be described as “stable” by their doctor, they are unable to resume their regular lifestyle because of the debilitating pain caused by the disease. Medication alone may not relieve the ongoing discomfort of chest pain and other symptoms of angina (the medical term for the discomfort, heaviness, pressure, or pain commonly experienced in your chest due to your heart disease). For many people, this is not an acceptable quality of life and in this case, your doctor may prescribe angioplasty and stents to relieve these symptoms.

    But I thought there was a recent study that said medications were just as good an approach for treating my heart disease as using stents? The study you are referring to, often called COURAGE, applies to the “stable” patient population. This study found that stable patients had the same likelihood of having a heart attack or dying regardless of whether they were treated with medications only or medications with angioplasty and stenting. The study did show that those patients having angioplasty were more likely to have less chest pain and take fewer medications specifically to treat those sympotns. The relief from pain and discomfort that typically follows from angioplasty and stenting is the reason that many patients elect the stenting option. These patients are much more likely to be able to resume normal lifestyle activities sooner with far fewer symptoms than many patients who choose the medications only route.  

    But what about safety? All medical treatments carry some risk, however small, but many studies have been completed that prove the benefits outweigh the risks most of the time.  Once risks are understood, there are ways to off-set the risk. For instance, drug-eluting stents (these are stents that are coated with drugs that help keep your artery from “reclogging”) offer the significant benefits of keeping your arteries open while also helping to avoid repeat procedures. There is a rare but serious risk with these types of stents, when compared with bare metal stents, of developing blood clots. This risk in a small portion of patients (0.5 percent) is greatly reduced if you stick with your regimen of anti-clotting medicine. If you elect angioplasty and stenting as your choice, it is essential that you take anti-clotting medication that your doctor prescribes for at least 1 year and possibly indefinitely. As we learn more about the longer-term results from these stents as well as from newer and better stents, we will be able to give you a better answer as to how long you may need to take these medications. You should NEVER stop taking your anti-clotting medicine without consulting your interventional cardiologist (the doctor who specializes in angioplasty and stenting procedures).

    Only by talking with your doctor about your condition, your goals for your health and the risks and benefits of each therapy, can you make the treatment choice that is best for your health and quality of life.