When deciding between angioplasty and CABG, a patient’s general health and other medical conditions are significant factors.
Within eight months, Marjorie McLaren, 62, of Lewisburg, Pennsylvania, underwent two cardiac catheterizations. Last May, she had emergency angioplasty at a local hospital. Then, in January, she had an elective blockage-clearing procedure at a large medical center – leaving her with a total of four arterial stents and several decisions along the way.
Heart Catheterization No. 1 – May 2014:
McLaren lives on a gentleman's farm where she tends to her horse and chickens. It was the middle of the night when she woke with what felt like “terrible reflux,” , other than making herself a cup of tea.
A few nights later, the same burning reflux-like pain jolted her from a sound sleep. She woke her husband, who drove her to the local ER. “That’s when they told me I was having a heart attack and they were going to do a catheterization on me,” she says. There was little time for discussion.
“It’s scary to have them going through your heart and putting stents in,” McLaren says. And she was surprised to learn that she’d had a previous heart attack at some unknown time – not to mention a complete blockage remaining in one artery that could not be repaired.
All was not well when McLaren returned to the farm. Despite being on a slew of heart medications, she became noticeably short of breath whenever she was active. “They were even discussing open heart surgery,” she recalls. “And I said no." Instead, she says, “If I was out walking or anything like that, I would just stop and catch my breath.”
Decision Points
Sometimes the choice is fairly obvious. A patient who has coronary artery disease involving severe blockages in major heart arteries – and who can withstand the grueling surgery – would likely undergo , or CABG. The breastbone is “cracked” and operate while the patient is on a heart-bypass machine. Full recovery, including , takes many weeks.
But another patient, brought to the ER in mid-heart attack, would quickly land in the catheterization lab to undergo a much less invasive procedure known as percutaneous coronary intervention, also called PCI or angioplasty.
With angioplasty, the patient has a small incision in the arm or groin. The threads a balloon-tipped catheter (a plastic tube) to the blocked blood vessel. The catheter holds a stent – a tiny expandable metal tube – used to crush the blockage and keep the artery open. Usually within a day or so, the patient is sent home to resume normal activity.
“The clearest situation where you would need PCI rather than surgery would be a person having an acute heart attack – the kind colloquially known as ‘the big one,’” says , director of cardiology at Geisinger Medical Center in Danville, Pennsylvania.
Blankenship describes one type of heart attack for which he says the clear choice is to “bring the patient into the cath lab, whack the artery open and put a coronary stent in.” It’s called an ST-elevation myocardial infarction, or STEMI, named after the EKG changes it causes.
Alternatively, certain patients would be much better candidates for CABG, says Blankenship, president-elect of the Society for Cardiovascular Angiography and Interventions. "The clearest instance would be where we find a blockage in the left main coronary artery,” he says. The left main is like a trunk, branching off into two crucial arteries supplying blood to the heart. If the left main is blocked, he says, “you’ve blocked off blood supply to two-thirds of the heart.”
A patient’s general health and other medical conditions factor into the decision between angioplasty and CABG. “Diabetes, particularly if you’ve got multiple blockages, favors bypass surgery,” Blankenship says. However, he says, patients with severe, chronic lung conditions could have trouble going off the ventilator after heart bypass. Advanced cancer or physical frailty might be other reasons to avoid the surgery.
Given a choice, most patients would choose stenting. But the results aren’t as durable, particularly for patients with multi-vessel disease. With angioplasty, these patients are to need a repeat procedure to restore blood flow to the heart. And their is higher than for patients undergoing CABG.
Informed Patients
For most of these decisions, “you should have a heart-team approach, which is generally having both a cardiologist and a surgeon talk to the patient,” Blankenship says. “The ideal informed consent is a setting where there’s no pressure. The patient is not on the table and has time to talk with friends, family and think about things and get opinions from different people.”
The SCAI’s patient-education site, Seconds Count, suggests regarding treatment options. For example, with stenting, you should ask about the and whether you’ll need a drug-eluting stent. A more basic question is whether your condition can be controlled by medication alone, procedure.
, director of electrophysiology at Cooper University Hospital in Camden, New Jersey, points out that besides deciding which procedure to have done, patients should carefully consider where to have it done.
“It’s very important to be at a center that has expertise at performing interventional procedures with good volume,” she says. “As with any interventions, there’s always a learning curve … the more volume you have, the greater chance there will be better outcomes.”
Heart Catheterization No. 2 – January 2015
When McLaren learned that Blankenship’s team at Geisinger – about 25 miles away – could perform a special catheterization procedure to open the remaining blockage, she was hesitant. But this time was different, she says: “It was a decision.” She had a chance to ask plenty of questions and learn about the risks involved and the results she could expect. “I felt more comfortable with the procedure and more confident,” she says. After talking it over with her husband, she says, the possibility of “being able to get up and move around and not be short of breath” made her decide to try it.
Overall, “the catheterization went well,” McLaren reports. Less anxious, she watched her heart beat and her lungs expand onscreen. "So that was interesting," she says. Because she developed a hematoma at the catheter insertion site in her groin, she had to stay at the hospital overnight to be monitored for possible bleeding complications. But the next day she was fine and went home. Now, she says, “I get up; I walk; I do my barn work. I don’t have shortness of breath – I feel pretty good.”