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Angioplasty & Stents - Angioplasty vs. Clot Busters

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

Is angioplasty better than clot busters?

A heart attack occurs when a blood clot lodges in one of the arteries supplying blood to the heart, usually one that is already narrowed by fatty plaque. The blocked artery can be cleared using angioplasty or clot busters—drugs that break up the clot. The sooner that blood flow is restored to the heart, the lower the risk of permanent damage occurring and the lower your risk of dying or having another heart attack.

Studies comparing angioplasty and clot busters show that angioplasty is better than clot busters at relieving symptoms in women with stable chest pain. In women who have unstable angina or a heart attack, angioplasty lowers the risk of dying or having another heart attack compared with clot busters.57 Women seem to especially benefit from angioplasty because they are generally at a higher-risk of dying to begin with due to their older age and higher rate of diabetes and high blood pressure. One study calculated that for every 1,000 women treated with angioplasty rather than clot busters, there were 56 fewer deaths, heart attacks, or strokes compared with 42 fewer events per 1,000 men.58

Angioplasty also has a higher success rate than clot busters, restoring strong blood flow to the heart in more than 90% of cases compared with 50% to 60% for clot busters.49, 59-61 The blocked artery is also less likely to renarrow after angioplasty than after clot buster treatment.28, 62

Does angioplasty have any special advantages in women?

Women in particular are better off with angioplasty because they are more likely to suffer a bleeding stroke hemorrhagic stroke when treated with clot busters. In one large study mentioned above, none of the women treated with balloon angioplasty suffered bleeding in the brain compared with 4.1% of the women treated with the clot buster tPA (tissue plasminogen activator). Less than 1% of men treated with clot-busters experienced bleeding in the brain. Other research confirms that there is virtually no risk of this serious complication with angioplasty.

If angioplasty is so much better, why use clot busters at all?

Firstly, the patients enrolled in research studies are carefully selected, and the benefits of angioplasty are less dramatic in the real world.63-65 Clot busters are easily injected through an IV line; angioplasty and stenting require doctors skilled in the procedure. In all of the studies that found angioplasty superior to clot busters, the procedures were done by experienced doctors at hospitals that do a lot of angioplasties. An analysis of more than 62,000 heart attack patients (30% were women) treated with either clot busters or angioplasty found that the risk of dying was lowest when angioplasty was performed at hospitals that did more than 49 procedures per year (far below current recommendations).66 There was no difference in the risk of dying between angioplasty and clot busters when angioplasty was performed at hospitals doing 16 or fewer procedures a year. Current guidelines note that the risk of dying is higher at hospitals that perform fewer than 36 angioplasties in heart attack patients per year (this number does not include non-urgent angioplasty procedures that are scheduled in advance). Angioplasty is also less beneficial when performed by doctors who do fewer than 75 procedures a year. When skilled staff are not available, clot busters are the favored treatment.

Is being transferred to another hospital for angioplasty better than clot busters?

Many hospitals do not have the facilities or experience to perform angioplasty. This has led researchers to test whether transferring heart attack patients to another hospital for angioplasty is better than treating them with a clot buster at the first hospital.

Studies so far suggest that transfer for angioplasty is better provided there are no extensive delays.67 Transfer patients experience fewer heart attacks and strokes, and in some—but not all—studies they were less likely to die than patients treated with clot busters.68 One Danish study was stopped early because it was unethical to continue given the large benefit seen for transfer patients.69 In this study, women transferred for angioplasty experienced nearly half as many deaths, heart attacks or strokes compared with women treated with clot busters. There is one problem with applying the results of these studies to everyday treatment, however: although patients transferred for angioplasty within 2 hours of reaching the first hospital have a lower risk of dying, in reality very few patients in the US are transferred this quickly.70

Again, it seems that being treated early is more important than which treatment you receive. In hospitals set up to perform routine angioplasty, there will be little time difference between the two treatments—although clot busters can be injected immediately into the arm through an IV line, the full effects of the drug are not felt until about 1 hour later. The most up-to-date US guidelines for heart attack treatment set a goal for treating transfer patients within 90 minutes of their arrival at the first hospital.54

When should using clot busters be considered?

For heart attack patients who arrive at the hospital shortly after their symptoms begin, the delay involved in receiving angioplasty may tip the balance in favor of clot busters. A research study that compared heart attack patients who were given clot busters in the ambulance with those who were treated with angioplasty when they arrived at the hospital found that patients treated less than 2 hours after their symptoms began were less likely to die when given clot busters. Of these patients treated early, 2.2% of the clot buster group died compared with 5.7% of the angioplasty group.71 The difference did not reach statistical significance but it was close and a similar trend has been seen in other studies. A review of 23 studies comparing angioplasty and clot busters found that the benefits of angioplasty were lost in angioplasty patients who waited more than 1 hour longer than clot buster patients for treatment.72 In light of these findings, current guidelines favor clot busters if angioplasty is likely to delay treatment by more than 1 hour and it is less than 3 hours since the heart attack symptoms began.54



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