Patient education: Angina treatment — medical versus interventional therapy (Beyond the Basics)

ANGINA TREATMENT OVERVIEW — In people who have coronary artery disease, the arteries that supply blood to the heart muscle get clogged with fatty deposits called plaques (figure 1). These plaques can reduce the flow of blood to the heart muscle, which can in turn cause chest pain or discomfort, especially during exertion. This chest pain is called "angina."

Angina can be "stable" or "unstable." Angina is unstable when there is a change in the usual pattern, such as a change in frequency, severity, duration, or precipitating cause. Unstable angina may be associated with damage to the heart muscle (or heart attack). The term "acute coronary syndrome" refers to people with unstable angina or a heart attack; these conditions require immediate evaluation in a hospital.

There are several treatment options for people with stable angina. These options are classified as optimal medical therapy (medications) and interventional treatment (procedures to open or bypass narrowed coronary arteries). 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 (called comorbid factors), 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. Optimal 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 education: Medications for angina (Beyond the Basics)".)

INTERVENTIONAL ANGINA TREATMENT — The interventional treatments for coronary heart disease include the following:

●Percutaneous coronary intervention (PCI) 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 patients with stable angina. Because these treatments actively restore blood flow to the heart muscle, they are often called revascularization procedures.

Stenting — Stenting, also known as "percutaneous coronary intervention" or PCI, is a procedure that uses a flexible plastic catheter with a tiny balloon at the end to dilate narrowed arteries in the heart. A metal stent is then placed at the site of a major blockage to hold the artery open. This procedure (which also used to be called "angioplasty") is discussed in detail in a separate article. (See "Patient education: Stenting for the heart (Beyond the Basics)".)

Occasionally it may be preferable to use balloon treatment alone without a stent (for example, for patients unable to take anticoagulation therapy).

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 veins used for the bypass are taken from the patient's own leg, and the bypass artery graft uses the patient's chest wall artery, known as the left interior mammary artery. CABG is discussed in detail in a separate article. (See "Patient education: Coronary artery bypass graft surgery (Beyond the Basics)".)

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 electrocardiogram 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 with increases in slope and speed at three-minute intervals (called stages I to IV) or on a stationary bicycle while an electrocardiogram is continuously monitored. In some cases, imaging with an echocardiogram or 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 whether medication, stent placement, or bypass surgery is the best choice.

Age — Interventional treatments have more risks in older people, especially those who are frail (this can be measured by a frailty score). With many more older patients undergoing CABG, the ability to select patients with good frailty scores has resulted in substantial improvements in outcome, both because of improvement in surgical care and patient selection.

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 stent placement 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, angiography followed by stent placement or coronary artery bypass graft surgery may be recommended.

For patients with chronic stable angina, stenting has not been shown to prolong life compared with medical therapy. It is used principally to improve angina symptoms when optimal medication therapy has failed. (See "Patient education: Stenting for the heart (Beyond the Basics)".)

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 progress to a serious condition called (congestive) heart failure. (See "Patient education: Heart failure (Beyond the Basics)".)

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 education: Heart failure (Beyond the Basics)".)

Narrowing of coronary arteries — The amount of myocardium at potential risk is a major factor in determining the recommendation for patients that fail optimal medical therapy. Patients with severe disease in all three coronary arteries or in the left main coronary artery are advised to undergo intervention, most often CABG, although stent placement may also be an option, especially for those patients with high operative risk because of comorbidity (other major organ involvement) or high frailty.

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 extensive peripheral vascular disease have greater risks from angioplasty and bypass surgery, and medical treatment may therefore be a better choice. (See "Patient education: Peripheral artery disease and claudication (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Coronary artery disease (The Basics)
Patient education: Chest pain (The Basics)
Patient education: Medicines after a heart attack (The Basics)
Patient education: Cardiac catheterization (The Basics)
Patient education: Medicines for angina (chest pain) (The Basics)
Patient education: Stenting for the heart (The Basics)
Patient education: Treatment choices for angina (chest pain) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Medications for angina (Beyond the Basics)
Patient education: Stenting for the heart (Beyond the Basics)
Patient education: Coronary artery bypass graft surgery (Beyond the Basics)
Patient education: Heart failure (Beyond the Basics)
Patient education: Peripheral artery disease and claudication (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Early cardiac complications of coronary artery bypass graft surgery
Early noncardiac complications of coronary artery bypass graft surgery
Coronary artery bypass graft surgery: Graft choices
Chronic coronary syndrome: Indications for revascularization
Periprocedural complications of percutaneous coronary intervention

The following organizations also provide reliable health information.

●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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