February 2008
Understand heart-disease treatment strategies
When an artery blockage is severe enough to be life threatening, or when lifestyle changes and medication don’t stop angina,
or cause intolerable side effects, it's time to consider either angioplasty or bypass surgery to restore circulation to the
heart.
But don’t agree to surgery unless you absolutely need it.
Start with lifestyle changes and meds, when possible
If angiography reveals significant narrowing in the heart’s main artery or three other major arteries, bypass surgery is required to prevent an imminent heart attack. If there’s no such narrowing, people with angina should almost always start with lifestyle changes and medication.
Click on the links at left for advice regarding lifestyle changes that can help prevent and reverse heart disease and its symptoms. In the links, you’ll also find advice regarding symptom-specific meds. You and your doctor can decide on a treatment plan, but drugs and supplements that are common among people with heart disease are:
Consider angioplasty if other options fail
Research now shows that angioplasty saves lives only when done within hours of a heart attack. At other times it just relieves angina, or chest pain during exertion. And lifestyle changes (diet and exercise) plus medication are usually the best first treatments for angina.
In angioplasty, a tiny balloon is snaked through a small incision in the groin and up into a narrowed coronary artery; then it’s inflated to crush the plaque deposit that's restricting blood flow and causing angina. Finally, a stent is almost always inserted to prevent renewed narrowing.
But diseased arteries typically contain additional plaque deposits too small and numerous to be treated with angioplasty. Researchers now know that the vast majority of heart attacks occur not when a large plaque deposit blocks an artery but when inflammation, high blood pressure, or other factors cause a smaller, less-stable deposit to rupture, producing an artery-blocking blood clot.
“Preventing those small, vulnerable deposits from developing and bursting is the key to preventing heart attacks,” says Steven Nissen, M.D., president of the American College of Cardiology. “And neither angioplasty nor stenting accomplishes that,” Nissen says.
In general, agree to angioplasty plus stenting only if you’ve just had a heart attack, or if angina severely hampers your lifestyle. In other cases, first try medication and lifestyle changes for three to six months.
If your doctor does recommend angioplasty, ask whether you’re a better candidate for drug-coated stents (better for individuals with one or possibly two uncomplicated plaque deposits who don’t have diabetes or kidney disease), or bare-metal stents—or for bypass surgery. Take anticlotting medications, usually aspirin and clopidogrel (Plavixand generic), for at least a year after any stent implantation.
Minimally invasive bypass
In the standard operation, the surgeon splits the breastbone, reroutes the blood through a heart-lung machine, stops the heart, grafts veins around the blockages, restarts the heart, and wires the chest back together. Patients usually spend four or five days in the hospital and recover fully within three months.
The new minimal bypass procedures are less traumatic, encouraging faster recovery, though they're appropriate only for certain patients. The most common approach requires only a 3-inch incision and several small puncture sites. Using special tools, the surgeon immobilizes part of the heart long enough to graft one or two non-cardiac vessels onto the front of the heart without stopping the heart.
Studies suggest that minimal surgery costs less and poses less short-term risk of major complications, notably stroke, kidney damage, and possibly mental impairment. But there’s still little long-term evidence.
Our consultants say the new bypass techniques are most likely to help people who clearly need bypass of one or two blocked arteries on the heart’s front but face a high risk of complications from standard surgery because of other risk factors.
However, the technique is still riskier and more invasive than angioplasty, so it shouldn’t be done when that procedure is appropriate.
If you need bypass of either type, seek a cardiologist who performs at least 75 angioplasties, or a cardiac surgeon who does at least 100 bypasses a year, preferably in a hospital where at least 400 angioplasties and 200 bypasses are performed annually. Even if you’re only having angioplasty, make sure the hospital has a back-up bypass-surgery team available during the procedure.
But don’t agree to surgery unless you absolutely need it.
Start with lifestyle changes and meds, when possible
If angiography reveals significant narrowing in the heart’s main artery or three other major arteries, bypass surgery is required to prevent an imminent heart attack. If there’s no such narrowing, people with angina should almost always start with lifestyle changes and medication.
Click on the links at left for advice regarding lifestyle changes that can help prevent and reverse heart disease and its symptoms. In the links, you’ll also find advice regarding symptom-specific meds. You and your doctor can decide on a treatment plan, but drugs and supplements that are common among people with heart disease are:
- A beta-blocker to help prevent angina (and reduce blood pressure)
- Nitroglycerin, a nitrate, to stop angina attacks.
- Low-dose aspirin to thin the blood.
- A statin, to lower LDL-cholesterol and reduce blood-vessel inflammation.
- An ACE inhibitor to lower blood pressure and relax the arteries, which makes it easier for the heart to pump.
- Omega-3 fatty acids, which inhibit clotting, lower blood pressure and triglycerides, and help maintain normal heart rhythms.
Consider angioplasty if other options fail
Research now shows that angioplasty saves lives only when done within hours of a heart attack. At other times it just relieves angina, or chest pain during exertion. And lifestyle changes (diet and exercise) plus medication are usually the best first treatments for angina.
In angioplasty, a tiny balloon is snaked through a small incision in the groin and up into a narrowed coronary artery; then it’s inflated to crush the plaque deposit that's restricting blood flow and causing angina. Finally, a stent is almost always inserted to prevent renewed narrowing.
But diseased arteries typically contain additional plaque deposits too small and numerous to be treated with angioplasty. Researchers now know that the vast majority of heart attacks occur not when a large plaque deposit blocks an artery but when inflammation, high blood pressure, or other factors cause a smaller, less-stable deposit to rupture, producing an artery-blocking blood clot.
“Preventing those small, vulnerable deposits from developing and bursting is the key to preventing heart attacks,” says Steven Nissen, M.D., president of the American College of Cardiology. “And neither angioplasty nor stenting accomplishes that,” Nissen says.
In general, agree to angioplasty plus stenting only if you’ve just had a heart attack, or if angina severely hampers your lifestyle. In other cases, first try medication and lifestyle changes for three to six months.
If your doctor does recommend angioplasty, ask whether you’re a better candidate for drug-coated stents (better for individuals with one or possibly two uncomplicated plaque deposits who don’t have diabetes or kidney disease), or bare-metal stents—or for bypass surgery. Take anticlotting medications, usually aspirin and clopidogrel (Plavixand generic), for at least a year after any stent implantation.
Minimally invasive bypass
In the standard operation, the surgeon splits the breastbone, reroutes the blood through a heart-lung machine, stops the heart, grafts veins around the blockages, restarts the heart, and wires the chest back together. Patients usually spend four or five days in the hospital and recover fully within three months.
The new minimal bypass procedures are less traumatic, encouraging faster recovery, though they're appropriate only for certain patients. The most common approach requires only a 3-inch incision and several small puncture sites. Using special tools, the surgeon immobilizes part of the heart long enough to graft one or two non-cardiac vessels onto the front of the heart without stopping the heart.
Studies suggest that minimal surgery costs less and poses less short-term risk of major complications, notably stroke, kidney damage, and possibly mental impairment. But there’s still little long-term evidence.
Our consultants say the new bypass techniques are most likely to help people who clearly need bypass of one or two blocked arteries on the heart’s front but face a high risk of complications from standard surgery because of other risk factors.
However, the technique is still riskier and more invasive than angioplasty, so it shouldn’t be done when that procedure is appropriate.
If you need bypass of either type, seek a cardiologist who performs at least 75 angioplasties, or a cardiac surgeon who does at least 100 bypasses a year, preferably in a hospital where at least 400 angioplasties and 200 bypasses are performed annually. Even if you’re only having angioplasty, make sure the hospital has a back-up bypass-surgery team available during the procedure.
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