Download Patient information: Angina treatment — medical versus

Patient information: Angina treatment — medical versus interventional therapy
(Beyond the Basics)
ANGINA TREATMENT OVERVIEW — Coronary heart disease causes narrowing of the
arteries that supply blood and oxygen to the heart muscle The consequences of coronary
heart disease include stable angina (intermittent but predictable chest pain), unstable angina
(angina that is new in onset, occurs at rest, or has a worsening pattern), heart attack
(myocardial infarction), or death.- both of these latter 2 are uncommon
There are several treatment options for people with stable angina. These options are
classified as medical treatment (which include medications and lifestyle modifications) or
interventional treatment (surgical treatment with percutaneous coronary intervention, with or
without a stent, or coronary artery bypass graft surgery). The choice among these treatment
options depends upon many individual factors, including a person's age, the severity of the
coronary heart disease, the relative risks and benefits of various treatments, the presence of
other medical conditions, and personal preferences.
Because coronary heart disease is typically a chronic disease requiring long-term treatment, it
is very important to learn as much as possible about this disease and about the benefits and
risks of the various treatment options. You should discuss all of these options with a
healthcare provider to determine which treatment is best.
GOALS OF ANGINA TREATMENT — All of the medical and interventional treatments for
people with coronary heart disease have the same goals: to improve quality of life and to
alleviate symptoms such as angina. In some people, these interventions may also delay or
stop the progression of the disease and thereby prolong life.
MEDICAL ANGINA TREATMENT — Medical treatment for coronary heart disease includes
drugs called antianginal drugs, which alleviate symptoms and support heart function. It also
includes lifestyle modifications. Medical treatment is usually considered first for all people with
coronary heart disease. Medical therapy is discussed in detail in a separate article.
INTERVENTIONAL ANGINA TREATMENT — The interventional treatments for coronary
heart disease include the following:

Angioplasty, with or without stent placement

Coronary artery bypass graft surgery (CABG).
These treatments effectively relieve symptoms of coronary heart disease, such as angina, but
they do not significantly increase life expectancy for most people. Because these treatments
actively restore blood flow to the heart muscle, they are often called revascularization
procedures.
Angioplasty — Angioplasty, also known as percutaneous coronary intervention, uses a
balloon to dilate narrowed arteries in the heart and may include placement of a stent to hold
the artery open. The procedure is discussed in detail in a separate article
Coronary artery bypass graft surgery — Coronary artery bypass graft surgery (CABG)
involves sewing one end of an artery or vein above a blocked coronary artery and the other
end below the blockage, thereby allowing blood an alternate pathway to the heart. The
arteries or veins used for the bypass (which are known as "grafts") are usually obtained from
the leg or the chest wall. CABG is discussed in detail in a separate article.
MEDICAL VERSUS INTERVENTIONAL ANGINA TREATMENT — Several factors can help
determine whether medical or interventional treatment is a better choice. You should discuss
all of these factors with your healthcare provider.
Results of studies — As a result of studies that compared medical to interventional
treatment, many experts do not recommend using interventional treatment initially unless you
have certain characteristics (see below) or you cannot tolerate or do not improve with
aggressive medical treatment.
Results of tests — Certain tests are used to determine the extent of coronary heart disease.
These tests may determine if medical or interventional treatment is more appropriate and can
help decide which interventional option (angioplasty or bypass surgery) is best. As examples:
Exercise ECG testing — An exercise test can often determine the severity of the narrowing
of the coronary arteries or if you have a risk of a heart attack or cardiac death. The test
involves running on a treadmill or bicycling while an electrocardiogram is continuously
monitored. In some cases, a radioactive tracer such as thallium or sestamibi is used to
identify the particular regions in the heart that are not getting enough blood.
Exercise or stress echocardiography this ultrasound test is often used to assess the
severity of any narrowing of the coronary arteries
Exercise testing provides information about the effects of coronary heart disease on the
heart's ability to function at different levels of exertion. Advantages of this test are that it is
noninvasive and particularly useful for identifying the small percentage of people with stable
angina who have a high risk of heart attack and death from their coronary heart disease.
Coronary Angiography — Angiography (also known as cardiac catheterization) involves
passing a small catheter into the coronary arteries. Dye is injected into the artery and an x-ray
image is used to show the outline of any blockages. Angiography is usually recommended for
people who are considered to have "high risk" disease based upon the results of other tests,
such as the exercise tests described above. The results of angiography can then help
determine if angioplasty or bypass surgery is a better choice.
Age — Interventional treatments have more risks in older people. For example, the risk of
dying from bypass surgery is about 3 times greater for people who are 79 years or older
compared to people who are 50 years of age.
On the other hand, older people often have the most to gain from bypass surgery; in older
patients (>75 years of age), bypass surgery has a greater life-prolonging benefit relative to
medical treatment. Therefore, advancing age does not necessarily rule out angioplasty or
bypass surgery as treatment options.
Severity of angina — People who have angina are usually managed with medical treatment
initially unless testing indicates that the person could have severe disease. If medical
treatment does not significantly improve symptoms of angina or if the person cannot tolerate
medical treatment, arteriography followed by angioplasty or coronary artery bypass graft
surgery may be recommended.
Angioplasty has not been shown to prolong life compared with medical therapy. Angioplasty is
used principally to improve angina symptoms when medications have failed
Advanced heart disease — Heart disease may lead to poor pumping function of the left
ventricle (the heart chamber that pumps blood to the body), and it may even lead to a serious
condition called heart failure.
People with these advanced types of heart disease may benefit more from interventional
treatments, primarily bypass surgery, than from medical treatment. In fact, interventional
treatment may even reverse abnormal function of the left ventricle in some cases. However,
interventional procedures are associated with greater risks in people with advanced heart
disease
Narrowing of coronary arteries — Interventional treatment is usually more beneficial than
medical treatment when the coronary arteries are severely narrowed, when many coronary
arteries are narrowed, and when the left main coronary artery (the artery that supplies blood
to the left side of the heart) is narrowed. These early patterns of arterial narrowing often
predict how severe heart damage would be if a heart attack occurs.

People who have at least three narrowed coronary arteries are usually advised
to undergo interventional treatment, most often bypass surgery.

People who have two narrowed coronary arteries are usually advised to have
interventional treatment.

People who have only one narrowed coronary artery are advised to use medical
treatment. If angina persists with medical treatment, then angioplasty, with or
without a stent, or coronary bypass graft surgery may be recommended.
Peripheral artery disease — Peripheral artery disease refers to narrowing of arteries in parts
of the body other than the heart. For example, arteries that supply blood to the arms and legs
or to the brain may be narrowed. Studies suggest that people with peripheral vascular
disease have greater risks from angioplasty and bypass surgery, and medical treatment may
therefore be a better choice.