Coronary Artery Disease: Should I Have Angioplasty for Stable Angina?

Angioplasty is a procedure to restore blood flow in narrowed coronary arteries.

During angioplasty, the doctor puts a thin, flexible tube called a catheter into an artery in your groin or arm. The doctor guides the tube into the narrowed coronary artery. Dye is put into the catheter to make the artery show up on an X-ray. This helps the doctor see narrow parts that limit blood flow.

The doctor uses the catheter to put a small balloon into the narrowed part of the artery. The doctor expands the balloon for a short time. This widens the artery to allow blood to flow more easily. The doctor may put a small, expandable tube called a stent in the artery to keep it open.

Before the procedure, you may get medicine that relaxes you or puts you in a light sleep. The area where the catheter is put in will be numb. You may feel a brief sting or pinch from the numbing medicine. Most people do not have pain when the catheter is in the blood vessel. You will probably feel some warmth when the dye is put in.

The procedure can take a few hours. This includes the time to get ready for the procedure and the time to recover after it. You may go home the same day. Or you may stay at least 1 night in the hospital. After you leave the hospital, you will avoid strenuous activity and not lift anything heavy until your doctor says it is okay. This may be for several days.

Treatment after angioplasty

It's important to continue medical therapy. This includes having a heart-healthy lifestyle and taking medicines to prevent a heart attack and stroke.

If you get a stent, you may take aspirin plus another medicine to prevent blood clots. How long you will take the medicines depends on the type of stent you have. If your stent is coated with medicine to prevent clots, you may take both medicines for at least 6 months. If your stent is bare metal, you may take both medicines for at least 1 month. After that, you will likely keep taking one of the medicines.

If you have a high risk of bleeding, your doctor may shorten the time you take these medicines. You can work with your doctor to decide how long you will take both of these medicines.

You may still need medicine such as nitroglycerin when you have angina symptoms. But you may not need to take it as often.

To have a heart-healthy lifestyle, be active, eat healthy foods, stay at a healthy weight, manage other health problems, and don't smoke.

Medical therapy includes taking medicines and having a heart-healthy lifestyle. Medical therapy is important for all people who have coronary artery disease. Whatever choice you make about angioplasty, medical therapy will give you the best chance of keeping coronary artery disease from getting worse. It can help you prevent a heart attack and live longer. And it also can help relieve angina symptoms.

Medicines

You take medicines to prevent a heart attack. These include aspirin and medicines to lower blood pressure and cholesterol. You also take medicine to relieve angina symptoms. Examples of angina medicines include nitroglycerin, beta-blockers, and calcium channel blockers.

Heart-healthy lifestyle

A heart-healthy lifestyle includes eating a healthy diet, not smoking, staying at a healthy weight, and getting daily exercise.

Your doctor may ask you to:

• Stop smoking. Quitting smoking can greatly lower your chance of having a heart attack and dying.
• Be active for at least 30 minutes on all or most days of the week.
• Eat heart-healthy food. These foods include vegetables, fruits, nuts, beans, lean meat, fish, and whole grains. Limit things that are not so good for your heart, like sodium, alcohol, and sugar.
• Stay at a healthy weight. Lose weight if you need to.
• Manage other health problems, including diabetes, high blood pressure, and high cholesterol.

After angioplasty, a cardiac rehab program can help you make lifestyle changes if you need to. Talk to your doctor about whether rehab is right for you. Cardiac rehab includes supervised exercise. It also includes help with diet and lifestyle changes and emotional support.

You may have had tests such as an exercise stress test or a coronary angiogram to see if you have narrowing of your heart arteries. If you do have narrowing, you may decide to have angioplasty because you want relief from angina symptoms. Angioplasty can improve symptoms for people who have stable angina. (Stable angina means that you can usually predict when your symptoms will happen. You probably know what things cause your angina. For example, you know how much activity usually causes your angina. You also know how to relieve your symptoms.)

Your doctor may suggest angioplasty if:^{footnote 7}

• Your angina symptoms keep you from enjoying your activities and your life.
• Medical therapy hasn't improved your angina enough.

It's important to talk with your doctor about your symptoms. Do they limit your daily activities and make it hard to enjoy your life? Do you have angina during light physical activity, such as walking a couple of blocks or up stairs? Also, if you are taking medicine for angina, let your doctor know if it doesn't control your symptoms enough.

Your doctor may do some other tests to make sure that angioplasty is a good choice for you. For example, your doctor may check:

• To see if narrowed arteries are limiting blood flow to your heart and causing angina.
• Which arteries—and how many—are narrowed. The doctor also will see how badly your arteries are narrowed. These tests can help your doctor see if bypass surgery might be a better choice for you.

You don't have to decide right away whether to have angioplasty. You could decide later to have it.

Angioplasty can improve your angina symptoms. It can also improve your quality of life. If your symptoms happen a lot, you are more likely to have a better quality of life after the procedure.^{footnote 10}

Angioplasty might not relieve all of your symptoms. But you might not need to take angina medicines anymore. Or you might not need to take as much.

There are some things that angioplasty can't do. In people who have stable angina:^{footnote 2}

• It does not prevent a heart attack.
• It does not help you live longer.

It may be hard to understand why angioplasty does not lower your risk of a heart attack or help you live longer. It's because of how coronary artery disease and plaque happen in your arteries.

Even if you get a stent, you still may have other places in your arteries where a heart attack can happen. During the procedure, your doctor finds and treats the places where plaque narrows the artery and limits blood flow. But smaller plaques can build up in other places in your arteries. They don't limit blood flow much or cause symptoms. But if one ruptures, it can cause a heart attack. This type of plaque is treated with medicines and a heart-healthy lifestyle.

Angioplasty has some risks. They include:

• The need for emergency bypass surgery during the procedure.
• Heart attack.
• Stroke.
• Death.

Your doctor can help you know your chance of problems from the procedure. Several things, including age and health, can raise your risk of problems. For example, older people or those with heart failure or kidney disease have a higher risk of problems.

The risks of problems where the catheter was placed include:

• Bleeding.
• Damage to blood vessels.
• Pain.
• Swelling.
• Bruising.
• Tenderness.

Over time, there is a chance that blood vessels with stents can close. There also is a chance that you'll need to decide whether or not to have another angioplasty or a bypass surgery.

Radiation: There is always a slight risk of damage to cells or tissues from being exposed to any radiation. This includes the low levels of X-ray used for this procedure. But the risk of damage from the X-rays is usually very low compared with the possible benefits of the procedure.

Benefits

Number of people with no angina after treatment^{footnote 13}

	After 3 months	After 2 years	After 3 years
Angioplasty plus medical therapy	53 out of 100	59 out of 100	59 out of 100
Medical therapy	42 out of 100	53 out of 100	56 out of 100

*These numbers are based on one research study.^{footnote 13}Another study showed a similar trend in symptom relief after angioplasty.^{footnote 10footnote 9}(Evidence quality: moderate.)

Both medical therapy alone (heart-healthy lifestyle and taking medicines) and angioplasty plus medical therapy can relieve angina. Angioplasty improves angina sooner. But over time, both treatments may work about the same to ease symptoms and improve quality of life.^{footnote 13footnote 10}

Take 100 people who had angioplasty in one study:^{footnote 13}

• After 3 months:
  • 53 out of 100 of people who had angioplasty plus medical therapy had no angina symptoms. That means 47 out of 100 had symptoms.
  • 42 out of 100 people who had medical therapy alone had no symptoms. That means 58 out of 100 did have symptoms.
• After 2 years:
  • 59 out of 100 people who had the procedure and medical therapy had no symptoms. That means 41 out of 100 had symptoms.
  • 53 out of 100 people who had medical therapy alone had no symptoms. That means 47 out of 100 had symptoms.
• After 3 years:
  • 59 out of 100 people who had the procedure and medical therapy had no symptoms. That means 41 out of 100 had symptoms.
  • 56 out of 100 who had medical therapy alone had no symptoms. That means 44 out of 100 had symptoms.

Doctors usually recommend that you try medical therapy first. This may include changing the dose of medicines or trying new medicines.

Medical therapy doesn't always work to relieve symptoms. But it does help to prevent a heart attack. You may decide later to have angioplasty if you still have symptoms that keep you from doing your activities.

Understanding the evidence

Some evidence is better than other evidence. Evidence comes from studies that look at how well treatments and tests work and how safe they are. For many reasons, some studies are more reliable than others. The better the evidence is—the higher its quality—the more we can trust it.

Another thing to understand is that the evidence can't predict what's going to happen in your case. When evidence tells us that 2 out of 100 people who have a certain test or treatment may have a certain result and that 98 out of 100 may not, there's no way to know if you will be one of the 2 or one of the 98.

Risks

The following numbers about risks come from problems seen in patients in hospitals.

Take 100 people who have angioplasty. They have the following risks:

Examples of angioplasty risks*

Possible problems from the procedure	How many people had this problem
Damage to the blood vessel where catheter is put infootnote 11, footnote 4	About 1 to 4out of 100
Bleeding problem during the procedurefootnote 8	About 1 or 2 out of 100
Emergency bypass surgeryfootnote 6	Fewer than 1 out of 100 people (4 out of 1,000)
Strokefootnote 1	Fewer than 1 out of 100 (2 out of 1,000)
Death in the hospitalfootnote 12	Fewer than 1 out of 100 (1 out of 1,000)

*Based on rates of complications from patients.