How is heart disease treated?

Heart disease used to be viewed as something of a plumbing problem. Under that model, doctors use tests to detect and then pinpoint blockages, which they "fix" using procedures to open up narrowed arteries or route blood flow around them.

Although that might help ease angina (aching, discomfort, or a burning or heavy sensation usually felt in the chest when you're active) in the short term, it won't necessarily prevent heart attacks. That's because those procedures usually treat isolated blockages, while diseased arteries typically have additional plaque deposits that are too small and numerous to be completely eradicated by them. And researchers now know that most heart attacks occur not when a large deposit blocks an artery but when other factors cause a smaller, less-stable deposit to rupture, producing an artery-blocking blood clot.

Those seeds are planted when high blood pressure, diabetes, smoking, or other factors injure the lining of the arteries, and cholesterol builds up at the damaged site. Treatment should always start by controlling those risk factors through diet, exercise, and medication.

Medical management

When appropriate testing confirms heart disease but shows no imminent threat of heart attack, the first step should be intensive medical therapy plus a long-term commitment to exercise and a heart-healthy diet. Current medical guidelines call for giving that conservative approach at least three to six months before resorting to more expensive and risky invasive measures.

Although some interventional cardiologists are quick to recommend angioplasty, also called percutaneous coronary intervention (PCI), to open constricted arteries, research has found that people who turn to lifestyle changes plus medical therapy are about as likely to be free of angina as those who also have angioplasty. More important, for people with stable coronary disease, there's no evidence that adding angioplasty, which tries to clear narrowed arteries by snaking in a tiny balloon and inflating it to crush plaque deposits, prevents heart attacks or other coronary events better than drugs and lifestyle changes.

Most people with heart disease will need to take several medications and at least one dietary supplement, as shown in the table below. For ACE inhibitors, beta-blockers, and statins, we've listed the specific drugs our experts recommend.

More-invasive approaches

If testing reveals severe blockages, you might need immediate angioplasty or bypass surgery. Bypass is generally called for when the heart's main artery or three other major arteries are occluded; angioplasty might be an option if one or two vessels are blocked. Bypass or angioplasty can also be appropriate if symptoms don't improve with drug therapy.

Doctors pinpoint blockages using angiography, a procedure that threads a flexible tube from the groin into the coronary arteries and injects a dye so that obstructions show up on an X-ray. Then they use angioplasty to clear the blockages. In most cases, the cardiologist will also place a cylindrical insert called a stent to keep the vessel open. Stents used in angioplasty today are usually coated with a drug to help prevent the artery from narrowing again. People who get a coated stent must usually take a blood thinner such as clopidogrel (Plavix) or prasugrel (Effient) for at least a year and low-dose aspirin for life.

Weighing your options

Some interventional cardiologists recommend angioplasty immediately after angiography reveals coronary narrowing, often while the patient is still on the table. But unless it's an emergency situation—for example, if you've just had a heart attack—there should be time to discuss various options with your treatment team and arrive at a strategy that works best for you.

If your doctor recommends either angioplasty or bypass, ask why lifestyle changes plus drugs aren't sufficient. If he or she recommends angioplasty, ask why that's preferable to bypass. And if he or she suggests bypass, ask about angioplasty. If you're not satisfied with the answers, consider seeking a second opinion.

Also ask about the doctor's skill and experience. For angioplasty, look for an interventional cardiologist who does at least 75 of the procedures a year and a hospital that does at least 400 a year. When choosing a bypass surgeon, there's more reliable information to draw on. See the ratings (available to subscribers) for how surgical groups across the U.S. performed based on national benchmarks.