Stable angina is caused by blockage of coronary arteries. In some cases, stable angina can point to a future heart attack.
The treatment for patients with stable angina should include medication and lifestyle changes. More aggressive treatment, such as the balloon and stent procedure or coronary artery bypass surgery (CABG), can also be beneficial. Which patients require only the conservative approach versus the more aggressive approaches is controversial.
The Courage Trial indicated that, in certain patients with stable angina, optimal medical treatment is comparable to the balloon and stent procedure in saving lives and preventing heart attacks. The balloon and stent procedure may, however, be better at reducing symptoms.
If you are already taking medication for stable angina, you should discuss how to optimize the therapy with your doctor. This may require a higher dose of what you're already on or additional drugs. Many cardiologists believe that the balloon and stent procedure or CABG should be reserved only for those with symptoms, despite their noted benefits, as they do carry notable risks.
Should I Just Take Medication?
I try an aggressive medical approach for all of my patients with stable angina prior to recommending either CABG or the balloon and stent procedure. There are fewer related risks, and treating stable angina with medication does not require an invasive procedure. Still, medication treatment is easier said than done. You may require a dozen pills per day, some of which may have side effects requiring even more pills. Additionally, changes in diet and exercise are a must. The effort and commitment to this “conservative” approach may be too much. Alternatively, even if followed to the letter, these efforts may not be enough.
Should I Have CABG?
If symptoms persist after medication has been tried, you may need CABG. Doctors and patients choosing between CABG and the balloon and stent procedure rely on information about the blockages' location. Bypass surgery may be recommended if all three of the major coronary arteries are blocked. Additionally, if a blockage exists in the left main coronary, or in the very early part of the left anterior descending (LAD) artery, CABG may be required. Finally, if a blockage is hard to reach with the balloon and stent equipment, CABG may be ideal.
The risks of CABG are significant. They include complications during surgery such as death, stroke, and kidney failure, as well as similar issues during recovery. Finally, the procedure itself usually does not last forever. New blockages may develop, requiring repeat procedures (such as another CABG or a balloon and stent) to treat them. CABG requires several weeks to months of recovery.
Should I Have the Balloon and Stent Procedure?
This procedure may also be considered a necessity if medication has been tried, but has failed. Again, the location of blockages will determine if balloon and stenting is best. If the blockages are reachable and not among those that indicate the need for a CABG, balloon and stent may be the way to go. Also, diabetics tend to benefit more from the balloon and stent procedure than from medication alone.
The risks of the balloon and stent procedure include immediate risks from carrying out the procedure itself, such as catheter manipulation, contrast dye reactions, balloon inflation and stent insertion. Risks occurring at a later time include re-narrowing of the coronary artery (restenosis) and blood clotting (thrombosis). Another long-term concern is the need for aspirin and Plavix (clopidogrel). These medications may need to be to be taken for life. The benefits of these medications must be weighed against the increased risk of bleeding that they pose. As a matter of fact, many surgeons will not operate on a patient taking this combination of pills, putting the patient in a very difficult situation when considering future surgeries.
Discuss your expectations of each therapy and whether you can make the commitment to medical management alone with your doctor.
Sources:
Bhatt AB, Stone PH. Current strategies for the prevention of angina in patients with stable coronary artery disease. Curr Opin Cardiol 2006;21:492-502.Boden, WE, O'Rourke, RA, Teo, KK et. al. for the COURAGE Trial Research Group. Optimal Medical Therapy with or without PCI for Stable Coronary Disease..N Engl J Med. 356:1503, April 12, 2007.
Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina -- summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 2003;41:159-168.
Management of Stable Coronary Artery Disease. N Engl J Med; 357:17. October 25, 2007.