A consumer’s guide to heart procedures

Q: What is coronary angiography? 

Coronary angiography is an X-ray exam of the heart arteries done during a cardiac catheterization procedure that can help doctors see blockages. Doctors insert a catheter (a thin, hollow tube) into an artery, typically in the groin area, and snake it up to the arteries supplying the heart, where they inject a dye visible by X-ray. The pictures they take of the heart arteries are called angiograms.

Q: What is coronary angioplasty?

Coronary angioplasty, also called PCI, is intended to open blocked arteries that supply blood to the heart. Doctors thread a balloon-tipped catheter, typically starting from an artery in the groin, to a significantly narrowed spot in a coronary artery. They inflate the balloon to widen the narrowed artery so blood can flow more easily. They also usually insert stents – expandable, metal mesh tubes – to keep arteries propped open after the procedure. The stents often are coated with medications to help prevent re-narrowing.

Q: What are the benefits of angioplasty?

The medical community agrees that angioplasty can help save lives and minimize heart muscle damage in patients in the midst of a heart attack or other coronary emergencies by restoring blood flow to the heart muscle quickly.

Outside of cardiac emergencies, it also can help reduce the frequency and severity of angina, the chest pain or pressure that is a symptom of a temporary lack of blood flow to the heart muscle.

Q: Is angioplasty a good option if patients aren’t having a heart attack?

This is where the medical community starts to disagree. Outside of emergencies, angioplasty in patients with stable coronary artery disease generally is considered elective. As with all elective procedures, doctor preferences and patient demand can drive usage patterns.

Some prefer angioplasty because it can reduce angina symptoms, in some cases more quickly than with medication alone, and decrease the dosages of ongoing medications patients need afterward.

Other doctors and patients prefer a non-invasive approach, opting to control the disease and reduce symptoms with medication and lifestyle changes, such as losing weight and quitting smoking.

Q: Is one option medically better than the other?

A well-known medical trial, known as the COURAGE trial, tackled this question and the results were published in The New England Journal of Medicine in 2007. For those patients with stable coronary artery disease who participated, angioplasty was no better than medication at reducing the long-term risks of death, heart attack or other major cardiac emergencies. While it reduced angina more quickly than medication alone, after five years nearly three-quarters of patients from each treatment group did not have angina symptoms.

Q: Why not choose angioplasty?

Angioplasty is more expensive for consumers, insurers and taxpayers than managing the disease with medication.

And as with any invasive procedure, there are risks associated with it. Doctors say complications are uncommon, but can include infection or bleeding at the catheter insertion site; blockages re-forming after a stent is implanted; and heart attack, stroke or life-threatening bleeding during or after the procedure.

Q: How has the use of angioplasty changed since the COURAGE trial was published?

In California, the rate of elective angioplasties decreased steadily between 2005 and 2009, but the largest drop came between 2006 and 2007, according to Laurence Baker’s analysis of California hospital discharge data. A national follow-up study to the COURAGE trial, published in May in The Journal of the American Medical Association, found that there is still much room for improvement and that less than half of patients with stable coronary artery disease undergoing angioplasty are on the appropriate medication before their procedures.

Source: CHCF Center for Health Reporting research