Is This Angiogram / Angioplasty Necessary?

Current Postings (6):

• Tom -- sorry you're confused -- hopefully it's not because of our articles, but because there has been much confusion around the results of the COURAGE trial. OK. Number one. A blockage does not necessarily mean you're at risk for a heart attack. It is currently believed that heart attacks are caused by "vulnerable plaque", a coronary artery plaque that ruptures releasing all kinds of thrombus-inducing material into the blood stream, causing clots, and subsequent blockage of blood flow. These plaques are not necessarily large ones that would be seen on angiography. However, they CAN be seen using other techniques, such as intravascular ultrasound (IVUS). The question on whether opening up any blockage is always, "Is it obstructive?" That is, does it reduce blood flow to the point that (1) it causes angina; or (2) it is so narrow, and in a major artery, that any small clot could cause a major event. To answer your question, all these trials and studies try to point to what could be called "best practice". What the COURAGE trial DID show was that stenting could be safely deferred in the patient population covered by the COURAGE trial -- namely low risk patients with stable angina. Other types of patients, such as the scenario you describe, cannot be automatically included.
Angioplasty.Org Staff, Angioplasty.Org, April 23, 2007

• After reading Angioplasty.Org's articles commenting on the "COURAGE" TRIAL", I am little confused. What about this scenario: An individual is currently experiencing NO angina or other symptoms, but since routine tests are questionable, a subsequent angiogram reveals previous double-bypass done four years ago has failed (closed), and patient is back where he started from with 80% blockages involving the distal left main & the ostium of the left circumflex artery & the left anterior descending artery (but, as I said, with No current angina). Are we to conclude that since this time there is no angina or other symptoms, that rather then using stents or attempting another bypass that the patient should initially treat this with medications only? And if so, is not the patient risking a sudden massive heart attack during this treatment, since blockages in those areas are rather serious?
Tom T., Arizona, USA, April 23, 2007

• Jay -- read the articles listed in the right-column side-bar. They talk about the COURAGE trial which showed that angioplasty and/or stenting did not prolong life or prevent heart attacks in patients with stable angina and relatively low risk blockages. Stents did, however, reduce angina (chest pain) and improve exercise tolerance better than drugs alone -- which is really why angioplasty is used. There has never been a study demonstrating that stents or angioplasty prolong life or prevent heart attacks better than drugs. We recommend that you inform yourself and then discuss these issues with your cardiologist. Many have warned against the oculo-stenotic reflex -- where cardiologists do diagnostic catheterizations and, if they see a blockage (a.k.a. stenosis), they unblock it in the same session. There are plusses and minues to this approach, also called "ad hoc angioplasty". The plusses? The patient doesn't need to undergo a second catheterization. The complication rate for catheterization is somewhere between 3-6%, mostly around the femoral artery entry point. So by doing everything in the same session you minimize the complications. Also the cost is reduced. The minuses? You eliminate a less invasive option, which is trying medical therapy to alleviate the symptoms and going back with a stent only if that doesn't work. All of this is a complicated issue. Our advice is to discuss these concerns with your interventional cardiologist BEFORE getting into the cath lab -- decide together what the best course of action is, and then proceed in confidence and understanding that you are doing the right thing. You might also ask whether a 64 slice CT scan might be a less invasive diagnostic first step. Again, your cardiologist may have very specific and very good reasons for stenting. And there's no problem asking what they are.
Angioplasty.Org Staff, Angioplasty.Org, April 23, 2007

• Thank you for your web-site and its wealth of information. I am 49 y/o man, active with no symptoms of heart disease. I have mild hypertension and a family history of heart disease. Last week I had a stress test at my first-ever visit to a cardiologist. They suggested angiogram immediately, and informed me if they found blockages, they would treat then-and-there with angioplasty and stents. I am concerned about doing too much too quickly. Are there alternative treatments to using stents?
Jay B., Arizona, USA, April 23, 2007

• VL -- 70% blockage is what the very provocative COURAGE trial just looked at, and found that in low risk patients with stable angina, there was no difference in survival or incidence of heart attack between those who had optimal medical therapy or those who also had a stent placed. The take-away from the study was that for those patients, there was no "emergency" to have a stent placed. Of course, you need to discuss with your cardiologist if you are part of the patient population studied in the COURAGE trial -- or at higher risk.
Angioplasty.Org Staff, Angioplasty.Org, April 12, 2007

• I have a 70% blockage of right anterior artery, diagnosed by angioplasty, 65% EF, just became 78yrs, female. Dr. says I must have stent or heart attack. Scheduled for Apr. 19, but wonder why there is such a hurry. I have a cat scan coming up in June to check for metastasis and am concerned about being on plavix if surgery is needed. I am asymptomatic and would like to delay stenting. Am I being unrealistic?
VL, Florida, USA, April 7, 2007