Angioplasty & Stents

What is balloon angioplasty and stent placement?

During balloon angioplasty a long, thin tube called a catheter is inserted through an artery in your groin or forearm, and a thin wire known as a guide wire is used to guide the catheter into the various arteries of the heart. The catheter has a small balloon at its tip that is inflated to push the fatty plaque blocking the artery back against the artery wall. Balloon angioplasty is nearly always combined with stent placement, when a tiny wire-mesh tube is inserted into the artery to prop it open.

Balloon angioplasty is also known as percutaneous transluminal coronary angioplastyor PTCA. These days, the term most doctors use is percutaneous coronary intervention or PCI. This refers to a variety of devices used to treat clogged arteries, including balloon angioplasty, stents, and atherectomy devices that cut away at hardened plaque. In 2004, almost 1.3 million PCI procedures were performed in the US, 34% of which were in women.

Are women undertreated?

Before doctors decide whether you need to undergo treatment such as balloon angioplasty or bypass surgery, they take an X-ray of the arteries of the heart to see whether there is a blockage present. This X-ray is called a coronary angiogram or, more generally, cardiac catheterization. As in angioplasty, a catheter is guided into the arteries of the heart, then a special dye, known as a contrast medium, is injected into the arteries that supply blood to the heart so that the X-rays can be taken. The angiogram can pinpoint the location and extent of any blockages.

A 1987 study of more than 80,000 heart disease patients showed that women were less likely to undergo cardiac catheterization than men. More recent research finds that women are as likely to receive this test if their age and risk factors are taken into account. Even so, a study using videotapes of actors describing identical chest pain symptoms found that the race and sex of the actor influenced the doctor’s decision to refer them for cardiac catheterization. Black women were less likely than white men to be referred for cardiac catheterization.

Once women undergo cardiac catheterization, they are just as likely as men to be treated with angioplasty or stents.

Angioplasty & Stents – Risks

What are the risks of dying after balloon angioplasty or stent placement?

Balloon angioplasty and stent placement are very safe procedures for women. On average, less than 1% of women undergoing routine angioplasty or stent placement die. The risks are slightly higher when the procedure is performed in an emergency situation such as during a heart attack, when as many as 5% of women may die. Death rates have fallen dramatically over the years as techniques have improved. Women undergoing modern procedures have a lower rate of death, heart attack, or need for bypass surgery than they did in the past, despite that fact that patients today are typically older and sicker.

Are women more likely to die after balloon angioplasty or stent placement?

When men and women are directly compared, women are more likely to die in the hospital. In general, balloon angioplasty and stent placement are riskier procedures for patients who are older or sicker, and those with smaller blood vessels. When these factors are considered, some studies find that women are no more likely to die in the hospital than men, whereas others continue to find a small gender difference.

Very few women younger than 50 years need to undergo angioplasty or stent placement because of the low rates of heart disease and heart attack in women of this age. However, when younger women have these procedures they are more than twice as likely to die in the hospital than younger men. In most studies, this gender difference remains even after risk factors and smaller size are taken into account. Why younger women are at a higher risk is not fully understood. It may be that younger women who lose their natural protection against heart disease are at especially high-risk compared with older women who develop heart disease after menopause.

Women who survive the hospital period do as well as men in the long-term. Studies consistently show that women who undergo angioplasty procedures are as just as likely to survive for 5 years.

Why do women have a higher risk of dying?

Angioplasty and stent placement are trickier to perform in smaller blood vessels, and there is an increased risk of tearing the artery. Women have smaller blood vessels than men, mostly because their bodies are typically smaller than men’s. But research also shows that women have smaller blood vessels even when compared with men of a similar size. In addition, smaller patients are more prone to bleeding problems during angioplasty and stenting.

Do women have more bleeding problems?

Women consistently experience more bleeding problems than men after angioplasty. In studies from the 1990s women were 2 to 3 times more likely than men to experience such complications during angioplasty procedures. In the early days of balloon angioplasty and stent placement, high doses of blood thinning medications were used increasing the risk of bleeding problems particularly among women, the elderly, and petite patients. Now, doses of blood thinning medications are adjusted according to the patient’s body weight, which reduces the risk of bleeding complications.

After angioplasty, the sheath that was placed when the catheter was inserted is removed. The more traditional method is to wait 4 to 6 hours until the effects of the blood thinning drugs have worn off and then to apply pressure while removing the sheath. Studies suggest that removing the sheath earlier reduces the risk of bleeding complications.

What other complications can occur?

A clogged artery that has been widened with balloon angioplasty can snap shut after the procedure. While rare, this complication has a high risk of death. It is far less likely to happen if a stent is left in place to prop open the artery compared with balloon-only angioplasty.

Angioplasty procedures may cause tears in the arteries of the heart. Women and the elderly are more prone to this rare but serious complication, probably because of their smaller blood vessels. These artery tears occur more often with devices other than balloons or stents, such as atherectomy devices that cut through hardened, fatty plaque. Atherectomy devices are generally larger than balloons or stents, and the procedure is more aggressive and thus more likely to injure the artery.

In rare cases, stent implantation damages the wall of the artery, triggering the formation of a life-threatening blood clot (thrombosis). Improvements in stent techniques and anti-clotting medications have greatly reduced the chances of this occurring. See the section on drug-coated stents for information about blood clot complications that may be related to this kind of stent.

Angioplasty & Stents – Effectiveness

How well does angioplasty work in women?

In terms of unblocking clogged arteries, angioplasty works equally well in men and women. Success rates of more than 95% are common for elective procedures that are scheduled in advance, and rates are similarly high for women who undergo angioplasty in an emergency situation such as during a heart attack.

Why are stents used instead of just balloon angioplasty?

In the US, balloon-only angioplasty is largely being replaced by stenting, although the use of stents varies widely between hospitals and from state to state. Stent implantation involves an additional step after balloon-only angioplasty. After the first balloon is inflated and the fatty plaque is pushed against the artery wall, it is removed and a second balloon carrying a stent is inserted. The second balloon is inflated, expanding the stent and lodging it in the artery where it remains.

When compared with balloon-only angioplasty, stenting has not been shown to reduce the risk of dying. Because stents stay inside the artery propping it open, they reduce the chances of the artery renarrowing (called restenosis). Between 20% to 50% of people treated with balloon-only angioplasty develop renarrowing of the artery compared with 10% to 30% of people who receive bare metal stents. The use of a drug-coated stent lowers the chances of renarrowing even more, to as low as 5% to 10%.

Are stents beneficial in women?

Early studies comparing stents with balloon-only angioplasty did not show a benefit for women. This is largely because the stents used were too big for women’s smaller arteries. Excessively high doses of blood thinning medications were also used at the time. More recent studies show that women treated with stents are less likely to develop renarrowing in the treated artery or require another angioplasty or bypass operation compared with women treated with balloon-only angioplasty. This benefit has been seen in women who receive stents in an emergency situation during a heart attack as well as women with stable symptoms such as chest pain.

When researchers pooled the results of 19 studies that compared stents with balloon-only angioplasty, there was a suggestion that stents may slightly reduce the risk of dying but only when they were used in combination with a type of blood thinning drug called glycoprotein IIb/IIIa inhibitors, the so-called “super aspirins.” A more recent study of 2082 heart attack patients (27% were women) found that stents reduce the risk of dying, having another heart attack or stroke, or needing another procedure compared with balloon-only angioplasty in both women and men.

Are stents better at relieving chest pain?

In terms of alleviating chest pain or angina, stents and balloon-only angioplasty are similarly effective. Patients treated with stents are more likely to feel chest pain after the procedure, this usually disappears within a few days and is generally considered harmless. One study comparing patients who felt chest pain after stenting with those who did not found that the chest pain group were more likely to require another angioplasty within 6 months.

What are drug-coated stents, and are they better than normal stents?

After a stent is implanted, it becomes embedded in the wall of the artery as scar tissue grows over it. Sometimes too much scar tissue grows, creating a new blockage and causing the artery to renarrow. Drug-coated stents have a thin coating of medication that helps prevent scar tissue from growing over the stent and causing renarrowing.

There is no evidence that drug-coated stents reduce the risk of dying or having a heart attack compared with bare metal (uncoated) stents. However, drug-coated stents do lower the chances of a blood vessel renarrowing or needing a repeat procedure, both in patients with stable chest pain and in heart attack patients. Women benefit from drug-coated stents as much as men.

Currently, there are two FDA-approved drug-coated stents: the CYPHER™ stent and the TAXUS™ stent. Each is coated with a slightly different drug. Both stents are combined with a regimen of one or more anti-clotting medications that must be taken for at least 1 year after the procedure. If you are having a stent procedure, discuss with your doctor whether you are a suitable candidate for a drug-coated stent.

As the use of drug-coated stents has become more widespread, there has been some concern that they increase the risk for serious blood clots (thrombosis) compared with normal stents. Thrombosis is a very serious complication: nearly half of patients die, and many others suffer heart attack or stroke. With bare metal stents, serious blood clots occur in less than 1% of procedures, usually within the first month after implantation. In patients treated with drug-coated stents, thrombosis may occur 6 months to a year later. Much controversy remains regarding how much drug-coated stents actually increase your risk of thrombosis. Recent studies suggest they may raise your risk by about 0.5%, or one case in every 200 patients treated. Taking a combination of blood thinning drugs after the procedure prevents the blood clots from forming, but many patients stop taking the medication early. Increased awareness of the importance of taking the medications, as well as the development of new stent designs, may be able to reduce the risk of this dangerous complication; several studies are currently underway. In the meantime, the medical community continues to debate how to prevent thrombosis, and whether it should make doctors more cautious about using drug-coated stents.

Timing of Angioplasty for Heart Attack

Research shows that balloon angioplasty and stenting are effective treatments for heart attack patients, including women. The longer you wait to seek treatment, the less effective angioplasty is the risk of dying is much lower when angioplasty is performed within 2 to 3 hours of when your symptoms begin. After 3 hours, the chance of dying does not increase a great deal whether you are treated within 3 hours, 6 hours, or 12 hours; however, you are more likely to experience another heart attack with these longer delays.

In addition to delays in seeking treatment, delays once you get to the hospital can make angioplasty less effective. Research shows that the chance or dying is higher if you are not treated within an hour of arriving at the hospital; two studies have found an increased risk of dying for each additional 15 minute delay. Most studies agree that hospital delays were critical only for patients who arrived at the hospital early on in their heart attack within 2 hours of when their symptoms began. People who arrived more than 2 or 3 hours after their symptoms began already had a higher risk of dying than those who arrived earlier, and this did not change much with in-hospital delays.

What is clear is that the earlier you are treated, the less likely you are to die or have another heart attack. But angioplasty remains an effective treatment for heart attack even if you wait before going to the hospital or experience in-hospital delays in receiving treatment. Current guidelines recommend that heart attack patients be treated within 90 minutes of arriving at the hospital; however, the most recent data available for US hospitals shows that patients wait an average of 185 minutes for angioplasty. Women and the elderly experience longer delays than men or younger patients.

Angioplasty vs. Clot Busters

Is angioplasty better than clot busters?

A heart attack occurs when a blood clot lodges in one of the arteries supplying blood to the heart, usually one that is already narrowed by fatty plaque. The blocked artery can be cleared using angioplasty or clot busters drugs that break up the clot. The sooner that blood flow is restored to the heart, the lower the risk of permanent damage occurring and the lower your risk of dying or having another heart attack.

Studies comparing angioplasty and clot busters show that angioplasty is better than clot busters at relieving symptoms in women with stable chest pain. In women who have unstable angina or a heart attack, angioplasty lowers the risk of dying or having another heart attack compared with clot busters. Women seem to especially benefit from angioplasty because they are generally at a higher-risk of dying to begin with due to their older age and higher rate of diabetes and high blood pressure. One study calculated that for every 1,000 women treated with angioplasty rather than clot busters, there were 56 fewer deaths, heart attacks, or strokes compared with 42 fewer events per 1,000 men.

Angioplasty also has a higher success rate than clot busters, restoring strong blood flow to the heart in more than 90% of cases compared with 50% to 60% for clot busters. The blocked artery is also less likely to renarrow after angioplasty than after clot buster treatment.

Does angioplasty have any special advantages in women?

Women in particular are better off with angioplasty because they are more likely to suffer a bleeding stroke hemorrhagic stroke when treated with clot busters. In one large study mentioned above, none of the women treated with balloon angioplasty suffered bleeding in the brain compared with 4.1% of the women treated with the clot buster TPA (Tissue Plasminogen Activator). Less than 1% of men treated with clot-busters experienced bleeding in the brain. Other research confirms that there is virtually no risk of this serious complication with angioplasty.

If angioplasty is so much better, why use clot busters at all?

Firstly, the patients enrolled in research studies are carefully selected, and the benefits of angioplasty are less dramatic in the real world. Clot busters are easily injected through an IV line; angioplasty and stenting require doctors skilled in the procedure. In all of the studies that found angioplasty superior to clot busters, the procedures were done by experienced doctors at hospitals that do a lot of angioplasties. An analysis of more than 62,000 heart attack patients (30% were women) treated with either clot busters or angioplasty found that the risk of dying was lowest when angioplasty was performed at hospitals that did more than 49 procedures per year (far below current recommendations). There was no difference in the risk of dying between angioplasty and clot busters when angioplasty was performed at hospitals doing 16 or fewer procedures a year. Current guidelines note that the risk of dying is higher at hospitals that perform fewer than 36 angioplasties in heart attack patients per year (this number does not include non-urgent angioplasty procedures that are scheduled in advance). Angioplasty is also less beneficial when performed by doctors who do fewer than 75 procedures a year. When skilled staff are not available, clot busters are the favored treatment.

Is being transferred to another hospital for angioplasty better than clot busters?

Many hospitals do not have the facilities or experience to perform angioplasty. This has led researchers to test whether transferring heart attack patients to another hospital for angioplasty is better than treating them with a clot buster at the first hospital.

Studies so far suggest that transfer for angioplasty is better provided there are no extensive delays. Transfer patients experience fewer heart attacks and strokes, and in some but not all studies they were less likely to die than patients treated with clot busters. One Danish study was stopped early because it was unethical to continue given the large benefit seen for transfer patients. In this study, women transferred for angioplasty experienced nearly half as many deaths, heart attacks or strokes compared with women treated with clot busters. There is one problem with applying the results of these studies to everyday treatment, however: although patients transferred for angioplasty within 2 hours of reaching the first hospital have a lower risk of dying, in reality very few patients in the US are transferred this quickly.

Again, it seems that being treated early is more important than which treatment you receive. In hospitals set up to perform routine angioplasty, there will be little time difference between the two treatments although clot busters can be injected immediately into the arm through an IV line, the full effects of the drug are not felt until about 1 hour later. The most up-to-date US guidelines for heart attack treatment set a goal for treating transfer patients within 90 minutes of their arrival at the first hospital.

When should using clot busters be considered?

For heart attack patients who arrive at the hospital shortly after their symptoms begin, the delay involved in receiving angioplasty may tip the balance in favor of clot busters. A research study that compared heart attack patients who were given clot busters in the ambulance with those who were treated with angioplasty when they arrived at the hospital found that patients treated less than 2 hours after their symptoms began were less likely to die when given clot busters. Of these patients treated early, 2.2% of the clot buster group died compared with 5.7% of the angioplasty group. The difference did not reach statistical significance but it was close and a similar trend has been seen in other studies. A review of 23 studies comparing angioplasty and clot busters found that the benefits of angioplasty were lost in angioplasty patients who waited more than 1 hour longer than clot buster patients for treatment. In light of these findings, current guidelines favor clot busters if angioplasty is likely to delay treatment by more than 1 hour and it is less than 3 hours since the heart attack symptoms began.

Angioplasty After Clot Busters

If clot busters fail, should you undergo angioplasty?

If clot busters fail to work, angioplasty is sometimes performed—this is called “rescue angioplasty.” There are no large studies testing whether rescue angioplasty works. Rescue angioplasty restores blood flow to the heart in a high number of patients but it is not clear whether this translates into a reduced risk of dying. Rescue angioplasty is much riskier than regular angioplasty because of the high risk of bleeding problems and complications. Women and the elderly are particularly prone to bleeding problems with rescue angioplasty. In addition, the chances of the artery renarrowing are higher after rescue angioplasty than after traditional angioplasty and patients who fail rescue angioplasty have a high risk of dying.

If clot busters worked, is there an additional benefit for angioplasty?

Historically, studies have found that routine angioplasty after successful clot buster treatment results in more bleeding problems, emergency bypass surgery, and a possible increased risk of dying. It has been argued that these studies are out of date because they were conducted before the wide use of stents and reduced doses of blood thinning medications. More recent studies are generally small, but several have found that angioplasty (with stents) after clot buster treatment reduces the risk of dying or having a heart attack and preserves heart function better than clotting medication alone, without an increase in bleeding problems.

Heart attack patients who continue to show signs of restricted blood flow to the heart after clot buster treatment are known to benefit from additional procedures. In this situation, angioplasty or bypass surgery reduces the risk of having chest pain or another heart attack, but does not prolong life.

What is “facilitated angioplasty”?

Angioplasty may be combined with lower doses of clot busters or with blood thinning drugs called glycoprotein IIb/IIIa inhibitors (the so-called “super aspirins”), or a combination of the two. This is known as facilitated angioplasty (the drugs facilitate unblocking the clogged artery). Research suggests that combining angioplasty and low-dose clot busters is no better than angioplasty alone for reducing the risk of dying or having a heart attack or stroke. There is a suggestion that it restores stronger blood flow to the heart than angioplasty alone. The facilitated angioplasty strategy may offer some advantages over clot busters alone, however, this treatment has a higher risk of bleeding problems. Current guidelines state that this facilitated strategy may be considered for high-risk patients when there is likely to be a long delay before angioplasty and there is a low risk of bleeding.

Angioplasty & Stents – Other Devices

What devices besides balloons and stents can be used?

In addition to balloons and stents, other devices are sometimes used during angioplasty. These include diamond-tipped atherectomy devices that break up hardened plaque, rotating blades that cut through the blockage, and laser-tipped catheters to zap the plaque or blood clot into tiny pieces that are washed away into the bloodstream. These devices are rarely used instead of balloons or stents but they may be used to pre-treat problematic blockages for example, one that is very hard or calcified. Because these techniques are more traumatic to the blood vessel than balloons or stents they have a higher rate of complications, including tears of the artery. Women are more susceptible to these complications, probably because their blood vessels are smaller.

What are distal protection (clot-catching) devices?

During angioplasty, the blood clot and fatty plaque blocking the artery is broken up into smaller pieces and washed into the bloodstream, but it is not removed. There is some concern that these smaller pieces may cause problems further downstream, perhaps blocking or restricting blood flow in some of the tiny blood vessels. Distal protection devices, so-called because they protect areas distal to (far away from) the actual blockage, capture and retrieve blood clots and fatty plaque.

Distal protection devices have mostly been studied in bypass surgery patients who develop blocks in their bypass grafts (the healthy artery sewn around the blockage to allow blood flow to bypass it). However, some small studies have found that they also have benefits when used for angioplasty in patients with unstable angina or a heart attack, including increased blood flow to the heart and a lower risk of additional cardiac events during the first month after a procedure.

What are thrombectomy devices?

Thrombectomy devices remove blood clots or thrombus before angioplasty for a heart attack (“-ectomy” means “to cut out” as in tonsillectomy). As of yet, there are no large studies comparing these devices with regular angioplasty.

A pooled analysis of all the available studies on these devices suggests that they should be used selectively. Overall, they do not help reduce the chances of the artery renarrowing and they may in fact increase the risk of future problems including heart attack.

Angioplasty & Stents – Artery Re-narrowing

Why do arteries sometimes renarrow?

Unfortunately, blocked arteries that have been cleared with angioplasty and stenting often renarrow. After the procedure, scar tissue grows over the stent and it becomes embedded in the wall of the artery. Sometimes too much scar tissue grows and the artery renarrows. New desposits of fatty plaque may also contribute to this renarrowing. The medical term for renarrowing is restenosis ( stenosis means narrow in Greek), defined as a regrowth that blocks more than 50% of the artery.

How common is arterial renarrowing?

Between 20% and 50% of people treated with balloon-only angioplasty develop renarrowing of the artery. Because stents remain in the artery to prop it open, there is less risk of renarrowing when stents are used — it occurs in as few as 10% of patients who receive bare metal stents and 5% in those with drug-coated stents .

Some people are more susceptible to renarrowing—patients with diabetes or smaller blood vessels, for example. Doctors can look for restenosis by performing an angiogram (an X-ray of the blood vessels of the heart). But even if the angiogram shows that a treated artery has renarrowed, it should only be reopened if it is causing problems such as chest pain.

Are women less likely to experience renarrowing?

Some studies find that women treated with angioplasty are less likely to develop renarrowing than men. This seems counterintuitive since women have smaller blood vessels than men and smaller blood vessels are more susceptible to renarrowing. It has been argued that women only appear to develop restenosis less often because they are less likely to be sent for testing. In one study, X-rays of the heart six months after stent placement showed less renarrowing in women than men. However, 1 year later women were just as likely as men to need a repeat procedure and to complain of chest pain.

Generally, cleared arteries renarrow within 6 months to a year or else not at all. Blockages that develop after this time are not usually related to the first angioplasty. These blockages may be in a different artery or a different section of the treated artery.

How is renarrowing treated?

If the artery renarrows, you may be treated with a repeat angioplasty or stent placement. Stents are more effective than balloon-only angioplasty at reducing the chances of the artery renarrowing yet again. Even though arteries treated with stents in the first instance are less likely to renarrow, when they do, this type of restenosis (called in-stent restenosis) is particularly tricky to treat.

Radiation treatment (called brachytherapy or vascular brachytherapy) is currently the only approved treatment for in-stent restenosis. During brachytherapy, a cathetercontaining pellets of radiation is threaded into the blocked artery as in angioplasty or cardiac catheterization. This catheter is positioned so that the pellets are placed next to the scar tissue, where they zap it with radiation and clear the artery. The treatment usually lasts about 10 minutes and the radiation exposure is similar to a chest X-ray. Sometimes, a balloon with tiny blades embedded on the surface is used to cut away the scar tissue before radiation treatment. The artery renarrows again in 20% to 25% of patients treated with radiation, requiring further treatment. Implanting an additional stent at the same time as radiation treatment appears to do more harm than good.

Drug-coated stents are also proving effective at treating the renarrowing of arteries that have already been treated with plain metal stents.

Angioplasty for Mild Heart Attack

How does a mild heart attack differ from a typical heart attack?

During a typical heart attack, a blood clot lodges in one of the small arteries of the heart blocking blood flow to the heart. This produces an easily identifiable pattern during ECG or electrocardiogram testing (called ST-segment elevation). Some people do not have a complete blockage in the artery, instead the clot interrupts the blood flow only intermittently. This type of unstable angina or mild heart attack does not produce the typical heart attack pattern on the ECG; the pattern produced is usually called non-ST-segment elevation (or NSTEMI, pronounced en-stemee).

Is angioplasty an effective treatment for a mild heart attack

The benefits of angioplasty are well established in typical heart attack patients but it is less clear whether patients with unstable angina or mild heart attack (NSTEMI) should be treated so aggressively. For the past few years, researchers have been comparing two types of treatment a conservative strategy using medications first and saving invasive procedures for patients who do not respond to drugs or a more aggressive strategy where the patient is sent immediately for cardiac catheterizationand then treated with angioplasty or bypass surgery.

Which is better: invasive or conservative treatment

Recent studies have shown that the aggressive strategy reduces the risk of dying or having a heart attack, especially in high-risk patients. However; the benefits are less pronounced in lower-risk patients. There are 2 major studies that had conflicting findings for women – the FRISC-II study (the acronym stands for FastRevascularization during Instability in Coronary artery disease) and the TACTICS-TIMI-18 study (Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction).

The FRISC-II study found that men benefited from the aggressive strategy but women were no better off. The women treated with catheterization followed by angioplasty or bypass surgery were more likely to suffer problems than men treated this way. In contrast, TACTICS-TIMI found that women were better off with the aggressive strategy. One explanation for the different results is the much longer time delay before the angioplasty or bypass was performed in the FRISC-II study 7 days compared with 2 days in TACTICS-TIMI. This may mean that the researchers left it too late to see a benefit for the aggressive approach. Another explanation is that women treated aggressively in FRISC-II were just as likely to undergo bypass surgery as angioplasty. The women who underwent bypass surgery had a very high risk of dying within one year – nearly 10% died compared with only 1.2% of the men who had bypass surgery. In TACTICS-TIMI, women treated invasively were more likely to be treated with angioplasty than bypass surgery and there was a much lower risk of death for women who underwent bypass surgery.

How do doctors decide which treatment to use

While the results of large trials suggest that the aggressive strategy is usually the better choice, it should probably be used selectively rather than routinely. Patients with unstable angina or a mild heart attack who are considered high-risk seem to particularly benefit from the aggressive approach. Blood tests are one means to identify high-risk patients. When the heart muscle is damaged, proteins (called troponins) are released into the bloodstream. Women and men with high levels of these proteins are less likely to die or have a heart attack if they are treated with the early aggressive approach involving catheterization and angioplasty than if they are treated conservatively. That said, the aggressive approach may be unnecessary for low-risk patients. One analysis of TACTICS-TIMI-18 showed little or no difference between the invasive and the conservative strategy in low-risk patients.

Angioplasty & Stents – Choosing a Hospital & Doctor

How do I choose a hospital or doctor?

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys hospitals and other care facilities to determine whether they meet the quality standards for accreditation. You can look up a hospital’s accreditation status at

An important aspect of choosing a hospital and doctor for angioplasty is how often your particular procedure is done. Although hospitals that perform certain procedures more often have better outcomes, there is a wide range of variability. If possible, you should try to find out not just the number, but also the outcomes (the percentage of patients who died or experienced complications) for the angioplasties performed at the hospital you are considering. Even more important than the number of procedures the hospital performs is how many your doctor performed. You should look for a hospital that performs at least 200 angioplasties, and a doctor who performs at least 75, annually. The hospital should also have cardiac surgery facilities in the event of complications. Angioplasty itself is not a surgical procedure (your chest is not cut open); however, a small number of patients treated with angioplasty develop complications that require immediate bypass surgery.

You should talk to the doctor who referred you for angioplasty about your options in choosing an interventional cardiologist and hospital. Your choice of hospital is greatly influenced by your choice of physician, as most doctors are affiliated with one or two hospitals to which they typically admit patients. Also be sure to check with your health plan to see which hospitals and physicians are covered.
Obviously, you will have little or no choice in hospital or physician in an emergency situation such as during a heart attack. However, if you have already had a heart attack, or know that you are at risk, you should keep the address of the nearest hospital with emergency cardiac care facilities readily available. People who would especially benefit from angioplasty rather than clot busters (high-risk patients, for example) may be taken directly to a hospital capable of emergency angioplasty rather than to the nearest hospital.

Angioplasty & Stents – The Angioplasty Procedure

How do I prepare for balloon angioplasty or stent placement?

Tell your healthcare provider all of the medications that you are currently taking and ask whether or not you should take any of your medications the morning of the procedure. If you take an anticoagulant, such as warfarin(Coumadin), you may be asked to stop taking it before the procedure. If you have diabetes, you may have to stop taking your medications until the dye is cleared from your system. You will also be asked not to eat or drink anything after midnight the night before the procedure. Be sure to tell your healthcare provider if you are allergic to shellfish, iodine, or strawberries because the dye used in the procedure may trigger a similar allergic reaction.

What does the procedure entail?

Before the procedure, you will be asked about your medical history and you will be given blood thinners (such as aspirin) to prevent blood clots during the procedure. The nurse will insert an intravenous (IV) line into your arm, so that a mild sedative and other necessary medication can be given without further injections. You will be hooked up to an ECG so that your heart rate and blood pressure can be monitored. For this, small sticky patches with wires attached will be taped to your body. For longer procedures, a urinary catheter may also be inserted in your bladder.

The physician will insert a catheter or sheath in the femoral artery in your groin, but sometimes an artery in the elbow or wrist is used. The area will be cleaned, shaved if necessary, swabbed with antibacterial solution, and then numbed with a general anesthetic, which may cause a brief period of discomfort. The catheter is fed over a guide wire through the sheath in the artery and into the heart; there usually is no discomfort, though you should let someone know if you feel any pain.

You will be sedated but awake for the entire procedure. At times, your physician or other medical staff may ask you to cough, turn your head, or take a deep breath. In angioplasty, some chest discomfort similar to angina or a twinge in the chest may be felt when the balloon is inflated.

How long does the procedure take?

Your procedure can last anywhere from 1 to 3 hours, depending on the severity of your blockages.

What happens after balloon angioplasty or stent placement?

After the procedure is finished, you will be transferred to a cardiac recovery room. You may feel groggy from the sedative, and the catheter insertion site (arm or groin) may be bruised and sore. If the groin was used as the point of catheter insertion, you will be instructed to lie in bed with your legs out straight.

There are two techniques for removing the sheath that was placed at the beginning of the procedure when the catheter was inserted. The more traditional method is to wait 4 to 6 hours until the effects of the blood thinner drug you were given have passed and then to apply pressure while removing the sheath. Another method is to have the sheath removed directly after surgery and then to apply manual pressure to the area. A newly developed technique involves a hemostatic device, a small plug that closes the artery. It makes a tiny seal or stitch in the artery. This speeds up your ability to get out of bed. If the arm was the insertion point, you do not have to stay in bed.

Throughout the post procedure monitoring, the point of insertion will be checked for bleeding, swelling, or inflammation, and your vital signs will be continuously monitored. You should drink plenty of fluids to flush out the dye used in the procedure. If you feel any pain in your chest or see any bleeding at the point of insertion, tell the hospital staff immediately. You will usually stay overnight for further observation.

Who should not have balloon angioplasty or stent placement?

If you are pregnant, only urgent procedures will be performed — in the case of a heart attack, for example. Elective procedures — ones to treat non urgent blockages — should be scheduled for after the birth. If you have a history of being allergic to shellfish, iodine, strawberries, or X-ray dye, you should not undergo cardiac catheterization because of the risk of an allergic reaction. Also, if you have kidney disease, you should not have any test that requires the use of contrast dye.

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