Some doctors oversell artery-opening angioplasty

A heart attack in progress is a medical emergency. Blood flow must be restored to a blocked coronary artery, or one so narrowed by fatty deposits that it triggers intense chest pain and other symptoms at rest. Every minute the heart is starved of oxygen means more damage. "It's time for quick action, because that could help save more heart muscle," says Dr. Deepak Bhatt, a cardiologist at Brigham and Women's Hospital and professor of medicine at Harvard Medical School.

The leading way to nip a heart attack in the bud is artery-opening angioplasty. But not all angioplasties are 911s. About one-third are done to lessen chest pain that appears with physical activity or stress. This is the chest pain known as stable angina. Sometimes the prospective patient has no symptoms at all — just test results that indicate one or more clogged arteries.

Cardiologists continuously debate when it's appropriate to do non-emergency angioplasty. This week, two studies in JAMA Internal Medicine add some provocative new information: that incomplete or even misleading advice from doctors contributes to unnecessary angioplasties. And that's a problem because angioplasty can harm as well as help.

Overselling angioplasty?

Everybody with cholesterol-clogged arteries, a condition formally known as coronary artery disease, can lower their risk of having a heart attack by making healthier lifestyle choices and taking medications when necessary. Does angioplasty add anything extra? In people with stable angina, the best clinical trials to date say that opening narrowed arteries with angioplasty on top of risk-lowering care does not prevent heart attacks or death in people with stable angina, and it eases chest pain only temporarily. Based on a strict reading of current guidelines, the benefit of angioplasty ranges from "none" to "uncertain" in nearly half of people with stable angina.

And that potential lack of benefit must be balanced by the potential harms of angioplasty. These include bleeding at the puncture site, a small tear in the lining of the coronary artery, heart attack, and even death.

So why do people with stable angina get angioplasties anyway? The JAMA studies suggest that imperfect medical advice is an important contributing factor.

In one study, researchers scrutinized recorded conversations between cardiologists and their patients as they decided whether to proceed with angioplasty. Few of the doctors explained the uncertain scientific evidence for angioplasty in people with stable angina. Also, the researchers said, some doctors "implicitly or explicitly overstated the benefits," while underselling medication and lifestyle change. In some encounters, the doctors dominated the conversation, leaving the patient with little opportunity to raise concerns, or used technical jargon that most people don't understand.

The second study found that additional information can counter unrealistic assumptions about angioplasty. Researchers administered a short survey to about 2,000 people with stable angina. When provided with an explanation that angioplasty may not prevent heart attacks, the participants were less likely to want the procedure.

"These trials emphasize the importance of patient education as to what an angioplasty can or can't do, what causes a heart attack, and how to best prevent a heart attack," says Dr. James Kirshenbaum, a cardiologist at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School.

Mistaken faith

Quality counseling before angioplasty is especially important given the widespread belief that all blocked coronary arteries are ticking time bombs. "A lot of times when a patient has a diagnosis of significant coronary artery disease, they think it's a heart attack waiting to happen," Dr. Bhatt says. "It's not necessarily the case."

In the JAMA survey study, about 70% of participants incorrectly believed that angioplasty would lower their chance of having a heart attack. After receiving more information, the number of people with that false belief dropped by half.

At the core of the exaggerated faith in angioplasty is the notion that simply unblocking arteries "fixes" coronary artery disease. "People need to be disabused of the plumbing analogy," Dr. Kirshenbaum says. "Angioplasty does not eliminate the need to take medication and make lifestyle changes."

That's because stable angina or a heart attack are just the most dramatic local outbreak of a system-wide problem: deposits of sticky plaque in the arteries, or atherosclerosis. Clearing one large blockage doesn't affect smaller "silent" plaque deposits that could eventually rupture and trigger a heart attack. The way to lower that risk is eating a healthy diet, getting regular exercise, avoiding smoking and heavy alcohol consumption, and controlling high blood pressure, blood sugar, and cholesterol.

Take-home lesson

If you have stable angina, or a stress test shows that you have one or more narrowed coronary arteries, you may find yourself having a discussion with your doctor about angioplasty. He or she should mention first the many benefits of positive lifestyle changes. These can help ease angina symptoms over time, helps all the other arteries that nourish your heart, and benefit just about every other part of your body as well.

Medications are next on the list. You may be a good candidate for a statin and/or low-dose aspirin, both of which have been linked to lower heart attack rates. If you have stable angina, your doctor may recommend a medication to help with chest pain.

Angioplasty is generally last. It has not been shown to prevent heart attack or death on people with stable angina or symptom-less coronary artery disease. It also has risks. Angioplasty may be right for you, but if so your doctor should explain carefully why.