Angioplasty means that tubes are inserted into the arteries of people with reduced blood flow to their hearts. Then a balloon is blown up from inside the artery to widen the blocked artery at its narrowed point. To prevent the artery from narrowing again, a stent is usually inserted into that artery and left there permanently.
A study in this month's New England Journal of Medicine shows that angioplasty may not boost survival for heart disease patients. More than 1,200 patients were randomly assigned to have:
• angioplasty plus medication, or
• medication alone
to manage their heart disease and relieve chest pain. A 15-year follow-up shows that those who have had angioplasties do not live longer than those who received just medication (NEJM, Nov. 12, 2015). This supports other studies that have shown that some angioplasties should not have been done (The Journal of the American Medical Association, July 6, 2011).
Problems with Stents
A serious problem with this procedure is that the stent is a foreign body left in an artery and it increases risk for clots to block that artery in the future. People who have had stents put in the arteries leading to the heart take anti-clotting medication for the rest of their lives. If you take anti-clotting agents and you fall and hit your head, the anticoagulants put you at increased risk for bleeding into your brain. People who take aspirin or other anti-clotting medications would be wise to have another person present when they exercise or do anything that has a risk of falling.
Stents should be used to treat a heart attack that has just happened. A heart attack is a compete blockage of blood flow to a part of the heart. The person usually develops sudden chest pain from the blocked blood flow to part of the heart muscle. If the part of the heart muscle supplied by the blocked artery does not get blood flow immediately, it can die and then the heart muscle is replaced forever by scar tissue that can cause irregular heartbeats that can kill. When a stent is inserted during or immediately after a heart attack, it can save the person's life. However, the stent increases risk for clotting for the rest of that person's life.
In the United States, about one million angioplasties are done every year, of which about 500,000 are done in patients with narrowed arteries leading to the heart, but with no complete blockage. They have what is called stable heart disease. The NEJM study shows that putting stents into their arteries does not prolong their lives and has the adverse effect of increased risk for clotting in the future. As a result, they have to take anti-clotting medication for as long as they live. It is my opinion that these people should be treated only with medication and lifestyle changes. I think that stents should not be done as a routine procedure in people who are not having a current heart attack.
Heart Attack Warning Signs
1) If you have persistent or progressively worsening chest pain, go to an emergency room. You could be having a heart attack.
2) If you have chest pain that comes and goes, is not brought on by exercise, often occurs at rest or minimal exertion, usually lasts more than 20 minutes, is of recent onset, is sometimes worse than at other times, you are likely to have unstable angina and should see a doctor immediately. You could be having a heart attack or may have had a heart attack in the past.
3) If you have chest pain when you exercise or get excited, or chest pain that gets better at rest or after taking medication, you are likely to have stable angina and are at high risk for a heart attack. If you are not already under a doctor's care, make an appointment immediately.
Based on this new NEJM study and many others, I believe that people with stable heart disease should be told that angioplasty in people who are not having a heart attack has not been shown to prolong lives more than taking appropriate medication and making major, permanent lifestyle changes.
What Should Be Done for People Who Have Narrowed Coronary Arteries
All people with stable heart disease and anyone with narrowed arteries should be told that they are at high risk for heart attacks. They may be given:
• drugs to lower high blood pressure,
• drugs to treat high cholesterol, and
• aspirin to reduce the risk of blood clots.
They should also be given lifestyle-change counseling that is even more important than drugs. Their doctor will do tests to help decide if they have a complete blockage that may need immediate treatment.
Heart-Attack-Preventing Lifestyle Changes for Everyone
• Avoid smoking, second-hand smoke and third-hand smoke (living in rooms formerly inhabited by smokers)
• Avoid red meat, sugared drinks, sugar-added foods and fried foods
• Eat lots of fruits and vegetables
• Limit or avoid alcohol (maximum 2 drinks per day for a man, 1 per day for a woman)
• Avoid recreational drugs
• Lose weight if overweight
• Keep blood levels of hydroxy vitamin D above 55 nmol/L
• Try to exercise every day (check with your doctor)
• If you have chest pain or have any other reason to suspect increased risk for a heart attack, check with your doctor as soon as possible.
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