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Angioplasty & Stents - Effectiveness

Article Index
Angioplasty & Stents
Risks
Effectiveness
Angioplasty vs. Clot Busters
Angioplasty After Clot Busters
Other Devices
Artery Re-narrowing
Angioplasty for Mild Heart Attack
Choosing a Hospital & Doctor
The Angioplasty Procedure

How well does angioplasty work in women?

In terms of unblocking clogged arteries, angioplasty works equally well in men and women. Success rates of more than 95% are common for elective procedures that are scheduled in advance, and rates are similarly high for women who undergo angioplasty in an emergency situation such as during a heart attack.

Why are stents used instead of just balloon angioplasty?

In the US, balloon-only angioplasty is largely being replaced by stenting, although the use of stents varies widely between hospitals and from state to state. Stent implantation involves an additional step after balloon-only angioplasty. After the first balloon is inflated and the fatty plaque is pushed against the artery wall, it is removed and a second balloon carrying a stent is inserted. The second balloon is inflated, expanding the stent and lodging it in the artery where it remains.

When compared with balloon-only angioplasty, stenting has not been shown to reduce the risk of dying.30 Because stents stay inside the artery propping it open, they reduce the chances of the artery renarrowing (called restenosis). Between 20% to 50% of people treated with balloon-only angioplasty develop renarrowing of the artery compared with 10% to 30% of people who receive bare metal stents.31 The use of a drug-coated stent lowers the chances of renarrowing even more, to as low as 5% to 10%.32, 33

Are stents beneficial in women?

Early studies comparing stents with balloon-only angioplasty did not show a benefit for women.34, 35 This is largely because the stents used were too big for women's smaller arteries. Excessively high doses of blood thinning medications were also used at the time. More recent studies show that women treated with stents are less likely to develop renarrowing in the treated artery or require another angioplasty or bypass operation compared with women treated with balloon-only angioplasty.12 This benefit has been seen in women who receive stents in an emergency situation during a heart attack as well as women with stable symptoms such as chest pain.

When researchers pooled the results of 19 studies that compared stents with balloon-only angioplasty, there was a suggestion that stents may slightly reduce the risk of dying but only when they were used in combination with a type of blood thinning drug called glycoprotein IIb/IIIa inhibitors, the so-called “super aspirins.”36 A more recent study of 2082 heart attack patients (27% were women) found that stents reduce the risk of dying, having another heart attack or stroke, or needing another procedure compared with balloon-only angioplasty in both women and men.14

Are stents better at relieving chest pain?

In terms of alleviating chest pain or angina, stents and balloon-only angioplasty are similarly effective.37 Patients treated with stents are more likely to feel chest pain after the procedure, this usually disappears within a few days and is generally considered harmless.38 One study comparing patients who felt chest pain after stenting with those who did not found that the chest pain group were more likely to require another angioplasty within 6 months.39

What are drug-coated stents, and are they better than normal stents?

After a stent is implanted, it becomes embedded in the wall of the artery as scar tissue grows over it. Sometimes too much scar tissue grows, creating a new blockage and causing the artery to renarrow. Drug-coated stents have a thin coating of medication that helps prevent scar tissue from growing over the stent and causing renarrowing.

There is no evidence that drug-coated stents reduce the risk of dying or having a heart attack compared with bare metal (uncoated) stents. However, drug-coated stents do lower the chances of a blood vessel renarrowing or needing a repeat procedure, both in patients with stable chest pain and in heart attack patients.40-42 Women benefit from drug-coated stents as much as men.43, 44
Currently, there are two FDA-approved drug-coated stents: the CYPHER™ stent and the TAXUS™ stent. Each is coated with a slightly different drug. Both stents are combined with a regimen of one or more anti-clotting medications that must be taken for at least 1 year after the procedure.45, 46 If you are having a stent procedure, discuss with your doctor whether you are a suitable candidate for a drug-coated stent.

As the use of drug-coated stents has become more widespread, there has been some concern that they increase the risk for serious blood clots (thrombosis) compared with normal stents. Thrombosis is a very serious complication: nearly half of patients die, and many others suffer heart attack or stroke.47 With bare metal stents, serious blood clots occur in less than 1% of procedures, usually within the first month after implantation. In patients treated with drug-coated stents, thrombosis may occur 6 months to a year later. Much controversy remains regarding how much drug-coated stents actually increase your risk of thrombosis. Recent studies suggest they may raise your risk by about 0.5%, or one case in every 200 patients treated.45 Taking a combination of blood thinning drugs after the procedure prevents the blood clots from forming, but many patients stop taking the medication early. Increased awareness of the importance of taking the medications, as well as the development of new stent designs, may be able to reduce the risk of this dangerous complication; several studies are currently underway. In the meantime, the medical community continues to debate how to prevent thrombosis, and whether it should make doctors more cautious about using drug-coated stents.

Timing of Angioplasty for Heart Attack

Research shows that balloon angioplasty and stenting are effective treatments for heart attack patients, including women. The longer you wait to seek treatment, the less effective angioplasty is—the risk of dying is much lower when angioplasty is performed within 2 to 3 hours of when your symptoms begin. After 3 hours, the chance of dying does not increase a great deal whether you are treated within 3 hours, 6 hours, or 12 hours; however, you are more likely to experience another heart attack with these longer delays.48, 49

In addition to delays in seeking treatment, delays once you get to the hospital can make angioplasty less effective. Research shows that the chance or dying is higher if you are not treated within an hour of arriving at the hospital; two studies have found an increased risk of dying for each additional 15 minute delay.50-52 Most studies agree that hospital delays were critical only for patients who arrived at the hospital early on in their heart attack— within 2 hours of when their symptoms began.53 People who arrived more than 2 or 3 hours after their symptoms began already had a higher risk of dying than those who arrived earlier, and this did not change much with in-hospital delays.

What is clear is that the earlier you are treated, the less likely you are to die or have another heart attack. But angioplasty remains an effective treatment for heart attack even if you wait before going to the hospital or experience in-hospital delays in receiving treatment. Current guidelines recommend that heart attack patients be treated within 90 minutes of arriving at the hospital; however, the most recent data available for US hospitals shows that patients wait an average of 185 minutes for angioplasty.54 Women and the elderly experience longer delays than men or younger patients.55, 56



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