Patient information: Angina treatment — medical versus interventional therapy

ANGINA TREATMENT OVERVIEW

Coronary heart disease causes narrowing of the arteries that supply blood and oxygen to the heart muscle (figure 1). 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.

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. (See "Patient information: Angina treatment — medical therapy".)

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. (See "Patient information: Heart stents and angioplasty".)

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. (See "Patient information: Coronary artery bypass graft surgery".)

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 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 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.

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. (See "Patient information: Heart stents and angioplasty".)

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. (See "Patient information: Heart failure causes, symptoms, and diagnosis".)

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. (See "Patient information: Heart failure treatments".)

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 arterial disease — Peripheral arterial 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. (See "Patient information: Claudication (peripheral arterial disease)".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Angina treatment — medical therapy
Patient information: Heart stents and angioplasty
Patient information: Coronary artery bypass graft surgery
Patient information: Heart failure causes, symptoms, and diagnosis
Patient information: Heart failure treatments
Patient information: Claudication (peripheral arterial disease)

Professional Level Information:
Early cardiac complications of coronary artery bypass graft surgery
Early noncardiac complications of coronary artery bypass graft surgery
Long-term outcome after coronary artery bypass graft surgery
Medical versus interventional therapy in the management of stable angina pectoris
Periprocedural complications of percutaneous coronary intervention

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

      (www.nhlbi.nih.gov)

• American Heart Association

      (www.americanheart.org)

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