Angioplasty deemed unnecessary for many.

Angioplasty Deemed Unnecessary for Many

Balloon angioplasty, an expensive and invasive blood-vessel-opening procedure often performed within the first two days after a heart attack, appears in many cases to provide no clinical benefits over a more conservative strategy of "watchful waiting," according to a large, 24-center study released this week. The surprise findings, which suggest U.S. heart attack victims unnecessarily spend $200 million annually on the procedure, have major implications for the rapidly evolving field of cardiac care.

Most heart attacks result when a blood clot becomes lodged in a coronary artery already narrowed by fatty deposits, cutting off blood flow to oxygen-hungry heart muscle. Prompt treatment with clot-busting drugs has proved extremely effective in saving oxygen-deprived heart muscle from irreversible damage. Cardiologists often follow clot-dissolving treatment with angiography -- a means of visualizing the affected vessel. When angiography shows a vessel substantially narrowed and accessible by catheter, the physician may opt to perform angioplasty in the hope of preventing or delaying reocclusion.

The procedure, which involves snaking a catheter into the partially blocked vessel and briefly inflating a tiny balloon to compress deposits, has also become popular as a preventive therapy. Since angioplasty's introduction in 1977, however, a number of studies have suggested the procedure has limited value. Now new research, reported in the March 9 NEW ENGLAND JOURNAL OF MEDICINE, suggests that among heart attack patients already treated with clot-dissolving drugs, angiography and angioplasty may be necessary only for those who experience recurrent heart pains (angina) either spontaneously or in response to a stress test given before hospital discharge. For patients not experiencing such symptoms, the somewhat risky procedures can probably be skipped.

"This doesn't say that angioplasty is unequivocally bad. This is a refinement that allows patients to be selected for invasive therapy," says Eugene R. Passamani of the National Heart, Lung and Blood Institute in Bethesda, Md. "The study shows that you can trust the symptoms -- the development of spontaneous or exercise-induced angina -- to select patients for angioplasty."

Sponsored by the National Institutes of Health, the study followed 3,262 heart attack patients. Approximately half uniformly received angiography -- and, when appropriate, angioplasty -- 18 to 48 hours after their attack. Physicians treated the others with angiography and angioplasty only if the patients experienced chest pains indicating recurring cardiac oxygen deficiency. The study showed no significant differences in mortality or heart attack recurrence between the two groups after 42 days. The two groups showed no significant difference in ejection fraction, a measure of heart function, six weeks after initial hospitalization.

The findings suggest that as many as 40 percent of angioplasty procedures performed on heart attack survivors -- and 60 percent of angiographies -- may not be necessary. It also means that typical community hospitals can care for most heart attack victims without installing costly cardiac catheterization facilities.

"There is a wonderful aphorism from Hippocrates: 'Serious diseases require serious remedies,'" says Passamani. "What this [study] says is that the serious remedy of angioplasty can be reasonably reserved for folks who develop recurrent symptoms. It means reserving serious therapy for serious diseases."