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Angioplasty

MagazineJune 1993 (Vol. 4 Issue 3)Angioplasty

This so called miracle preventative for heart attacks usually isn't necessary

This so called miracle preventative for heart attacks usually isn't necessary. When it is, the effects don't last.

The number of deaths from heart disease reads like a terrifying roll call of modern times: in 1989, 1 million people died of heart disease in the US, and a further 160,000 in the UK.

The saddest element of an already tragic situation is that of the 1.5m people who suffer a heart attack in the US each year, just 350,000 live to tell the tale. In other words, the first heart attack is often the last.

Not surprisingly, medical research places great emphasis on understanding the causes, but to little effect. One study concluded that bald men are more likely to suffer from a heart attack than their hirsute colleagues (the fact that bald men tend to be older doesn't seem to have occurred to the researchers).

Virtually every week a piece of research is published, often offering contrary findings to a previous paper. Indeed, a recent paper reckoned that all the standard causes smoking, high blood pressure and cholesterol accounted for no more than 50 per cent of total risks (JAMA, 24 February 1993).

Even so, the death rate from heart disease fell by 30 per cent between 1979 and 1989 and, again, researchers don't seem to have an explanation, save that perhaps people are smoking less.

But despite all this uncertainty, one procedure coronary balloon angioplasty, or percutaneous transluminal coronary angioplasty (PTCA), to give it its proper name has come through as the major method of treating heart problems, particularly angina.

In this article, we explore the benefits and risks of the procedure, as well as other conventional practices, and the main alternative treatment, chelation therapy, and the latest theories about reducing the risks of developing a heart condition in the first place.

If you are one of the "lucky minority" to be diagnosed with a heart condition before suffering a fatal attack usually because of severe pains, breathlessness or difficulty in walking the chances are that your doctor will recommend angioplasty treatment.

Coronary balloon angioplasty has been in the ascendant since it was first mentioned in The Lancet in 1978. It is a relatively simple procedure and involves the threading of a tiny balloon through blocked arteries and expanding it to clear them, usually by pressing atheronatous (fatty) plaques against the coronary artery wall.

When angioplasty started to be used, the "gee whizz" technique was coronary bypass surgery, then one of the wonders of the modern medical world.

As angioplasty became more sophisticated, so it gained ground on bypass surgery. It was considered cheaper, easier to perform and far less traumatic and is now seen virtually as the heart disease cure all, offered to angina sufferers, those recovering from a heart attack, and as a just in case remedy for those concerned about the state of their arteries.

In 1990, 200,000 people in the US were treated with the procedure, and a further 100,000 in Europe, yet "only a few prospective trials had assessed its efficacy", stated the New England Journal of Medicine (2 January, 1992).

Not that the medical profession had much to worry about, it seemed. Initial tests showed an extraordinary success rate, some ranging above 90 per cent, with complications therefore in fewer than 10 per cent of cases. Even Mother Teresa, in her 81st year, received the treatment, giving it a by then unneeded added endorsement.

One of the most comprehensive surveys to date vindicated the results. Of 5,827 patients treated with angioplasty between January and June 1991 in the state of New York, 88 per cent were reported as being successful (JAMA, 2 December 1992). However, "no data on post discharge complications are available", stated the report in a throwaway line at the end, but one that hides the real long term efficacy of the treatment.

Ironically, it was The Lancet, the journal that had first announced the new wonder treatment, that was in the vanguard of those voicing concerns. A delegate from the journal attended an angioplasty course in 1991 and wrote that he "tended to take a less favourable view of the outcome than the clinician doing the procedure, and in general the results of coronary angioplasty seemed inferior to those reported in journals" (The Lancet, 14 November 1992).

In the US, an even more damning statement was issued by the American College of Cardiologists: "Observations raise the question of whether cardiology has focused too much on doing coronary angioplasty procedures rather than on addressing who needs it, what are the criteria, and what are the results. Is angioplasty being done for cardiologists or for patients?" This represented a remarkable volte face by a profession normally protective of its procedures.

Far from being an instant miracle cure all, the truth about angioplasty is much more complicated.

It is more effective for simple cases. A study in Boston, Mass., discovered that angioplasty patients with two to three risk factors had a survival rate over five years of just 13 per cent (New England Journal of Medicine, November 5, 1992).

Stenosis (narrowing of the artery) reoccurs within six months after angioplasty with the diameter of the blood vessel being only 16 per cent larger than before treatment (according to the American College of Cardiologists). In one Italian study restenosis occurred in 73 per cent of cases (New England Journal of Medicine, 10 October 1991).

Because of the need for continual retreatment and monitoring, the real costs of angioplasty may be much higher than those for medical therapy in cases of mild angina and single vessel disease. A separate study in Maryland, estimated that hospital charges had doubled in the 10 years angioplasty has been used (New England Journal of Medicine, 2 January 1992).

The efficacy of the treatment in triple vessel disease was further questioned by an Italian study which reported only a 52 per cent success rate in those cases. It was also successful in only 30 per cent of cases of total blockage of the artery (Journal of the American Medical Association, 6 January 1993).

It has a very low success rate with blocked arteries in the lower part of the body. Despite an increase in the use of the treatment from one per 100,000 to 24 per 100,000 from 1979 to 1989 in Maryland, the numbers of leg amputations remained constant at 30 per 100,000 (New England Journal of Medicine, 22 August 1991).

There is also strong evidence that many of the angioplasty operations carried out may be unnecessary. A damning American study (JAMA, 11 November 1992) looked at 171 patients who had earlier been referred for angioplasty and concluded that for half of them the operation wasn't needed or could be safely deferred. They also point out that coronary angioplasty was originally expected to replace bypass surgery, but in fact, both studies have grown in tandem, with neither reducing the frequency of the other. "Evident over the past decade is the ever lowering threshold for carrying out bypass as well as angioplasty. . . even asymptomatic patients are not exempt," they say.

Bypass surgery

A recent study by the University Hospital in Nottingham indicated that bypass surgery was a more successful treatment of angina than angioplasty. A survey of 1,011 patients showed that six times as many angioplasty patients needed repeat treatment or surgery as those who had bypass surgery. The report also found that angina was almost three times as common in angioplasty patients as in bypass patients within six months of the treatment (The Lancet, 6 March 1993).

However, as already indicated, bypass surgery is most appropriate in treating those with triple vessel disease (when two thirds of each artery is blocked). This covers just 10 per cent of all heart condition sufferers. Bypass surgery is, of course, a major and traumatic procedure, and the death rate has ranged from as low as 3 per cent to an alarming 23 per cent in the US.

In the 1970s, several major studies revealed that bypass surgery did not improve survival except among patients with severe coronary disease, particularly to the left ventricle. It did, however, relieve severe angina (New England Journal of Medicine, 2 January 1992).

Even though it is an appropriate treatment for just 10 per cent per cent of sufferers, the bypass seems to be surviving better than its patients. Perhaps this is not surprising when you consider that, in the US, it is one of the best paying surgical procedures, with surgeons earning about $40,000 an operation. Overall, the treatment costs Americans $5bn a year, to treat just 200,000 people.

Drugs therapy

Another route gaining credence in traditional medicine is thrombolytic therapy, drugs that break up clots. A recent study in Northern Ireland tested two of the drugs Kabikinase and Eminase on 37 patients in a 129 strong patient group. The 37 received early therapy, as soon as the symptoms of heart trouble were diagnosed, while the remainder were given the treatment only on admission to hospital.

Within 14 days, one patient on early treatment had died against 10 in the second group; after one year, two had died in the first group against 17 in the second. At the end of the two year trial, another four had died in the second group.

Clearly, drugs therapy is the least traumatic and least expensive of the routes. But while the Northern Irish study was testing the efficacy of the treatment on diagnosis, it also showed that the mortality rate by using the drugs was nearly 15 per cent, an uncomfortably high figure.

So what should you do if you are diagnosed as at risk from heart disease? Despite the impression given by many doctors, heart surgery is often not urgent. Dr Wayne Perry a proponent of chelation therapy as an alternative to surgery (see below) suggests patients should discuss with their doctor the possibility of deferring a heart operation for a year while they try other, less invasive methods of treatment, such as changes to diet, exercise and stress management programmes, possibly combined with chelation therapy. Only if these other methods don't work should you think about going ahead with surgery.


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