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Coronary Artery Disease and Angina

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of CAD.

Alternative Names

Angina; Angiography; Angioplasty; Atherosclerosis; Beta Blockers; Calcium Channel Blockers; Coronary Artery Bypass Surgery; Coronary Artery Disease

Surgery

To date, surgery is usually recommended for patients who have the following conditions:

  • Unstable angina that does not respond promptly to medical treatment.
  • Severe recurrent episodes of angina that last more than 20 minutes.
  • Severe coronary artery disease (e.g., severe angina, multi-artery involvement, evidence of ischemia), particularly if abnormalities are evident in the left ventricle of the heart, the main pumping chamber.
Atherosclerosis
Atherosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall, resulting in narrowing and eventual impairment of blood flow. Severely restricted blood flow in the arteries to the heart muscle leads to symptoms such as chest pain. Atherosclerosis shows no symptoms until a complication occurs.

Researchers have been investigating whether surgery offers any advantages if used as early treatment for mild angina. A major analysis in 2003 reported that the use of angioplasty in patients with mild heart blockage did not reduce the risk for heart attack or death over the long term.

Choosing Either Angioplasty or Bypass

There are two effective surgical procedures now available for heart patients:

  • Coronary artery bypass grafting (commonly called bypass or CABG).
Click the icon to see an image about bypass grafting.
  • Percutaneous transluminal coronary angioplasty (commonly called angioplasty or PTCA), usually with coronary artery stent placement.
Click the icon to see an image about bypass grafting.

Each of these procedures is described below.

Studies have generally reported similar survival rates with either procedure. There are some differences, however, and decision often depends on individual conditions. (Patients considering surgery should discuss all options and risks with their physician.) No surgical procedure cures coronary artery disease, and patients must continue to rigorously maintain a healthy lifestyle and continue any necessary medications.

Considerations for Choosing Angioplasty with Stent Placement. Angioplasty has the following advantages for most patients:

  • Angioplasty is less invasive than bypass. (Although a minimally invasive variation of bypass surgery may over time reduce this distinction.)
  • Angioplasty is initially less expensive. (Although the postoperative need for more medications and the high risk for repeat procedures to reopen the artery may reduce the long-term difference in cost between the two procedures.)
  • Angioplasty is an important and life-saving emergency procedure for many patients with heart attacks. (The use of bypass after a heart attack has much higher mortality rates than when it is used electively and its use is controversial in heart attack patients.)

It has the following disadvantages:

  • The blood vessels close up (restenosis) in a large minority of patients and require additional procedures. (New blood thinning agents, coronary stent coatings, and radiation treatments may help to significantly reduce restenosis rates.)
  • It is not as appropriate as bypass for many patients with angina (e.g., people with diabetes, elderly patients, or those with multi-vessel blockage). Increasingly, however, angioplasty is proving to be safe and as effective as bypass even in many of high-risk patients (other than people with diabetes). Even if the physician recommends bypass, patients should discuss the risks and benefits of angioplasty if they would prefer it.

Considerations for Choosing Bypass. Bypass is usually the appropriate procedure in patients with the high-risk conditions, such as the following:

  • Multi-vessel blockage. (In one report comparing surgery to angioplasty in patients with two or three blocked vessels, the mortality rate one year after bypass of 0.8% and after angioplasty was 2.5%. About 80% in the study were men.)
  • Diabetes. (Bypass produces significantly higher survival rates in these patients and some experts believe angioplasty should rarely, if ever, be used in this population.)
  • Being elderly.
  • Certain structural features, such as a left main artery narrowed by 50% or more or a very long diseased portion of the artery.

Considerations for Women. Studies have reported higher mortality rates in women than in men after any heart surgery. Some experts theorize that on average women may be older and sicker when they have a heart operation. A 2002 study, however, suggested that when women with acute coronary syndromes are given the same aggressive and early treatment as men are, their survival rates are equal or even better.

Other Procedures

In addition to angioplasty and bypass procedures, a number of other procedures are available or under investigation for coronary artery disease. They include the following:

  • Atherectomy.
  • Myocardial Laser Revascularization.
  • Enhanced External Counterpulsation (EECP).
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