Advances in Heart Attack Preventive Technology
Mechanical options with angioplasty and stents
With the development of coronary angioplasty and stenting, another approach to treating heart attack victims emerged. Instead of thrombolytic therapy, the patient is taken directly to a catheterization laboratory to undergo coronary angiography. The blocked artery is then opened with a balloon angioplasty, usually followed by stenting (implantation of a metal scaffold to maintain artery patency). When performed promptly (i.e. within 90 minutes of arrival at the hospital) this technique has a certain advantage over thrombolysis.
There is a greater likelihood of opening the blocked artery and a slightly lower mortality rate. In addition, the entire coronary anatomy can be evaluated. There is a lower risk of significant bleeding and virtually no risk of intracranial hemorrhage. Because of these advantages, immediate coronary angioplasty has become the preferred treatment of heart attacks in hospitals having facilities to perform the procedure.
Should all patients presenting to a community hospital be transferred to another hospital for urgent angioplasty? The answer depends on the time required to transfer to the catheterization facility. If the transfer cannot be accomplished within 90 minutes, thrombolytic therapy should be given at the community hospital to restore coronary flow as quickly as possible. In practice it is usually not possible to transfer a patient to a receiving catheterization lab in the prescribed period of time.
Great strides have been made since the introduction of thrombolysis and primary coronary angioplasty. The strengths and limitations of each of these modalities are becoming better defined. Thrombolysis offers an immediate treatment that can be delivered at any hospital or even in the field by emergency medical personnel. It provides an opportunity for the most rapid relief of coronary obstruction and is non-invasive.
Primary angioplasty can open virtually all acutely blocked coronary arteries, but usually with a longer delay to treatment. As with any invasive procedure, complications can occur at arterial puncture sites. The angiographic dye can have a toxic effect on the kidneys, and considerable radiation exposure is required for the procedure. In addition, coronary stents require careful long-term management. Anti-platelet treatment with aspirin and Plavix must be continued for many months, and possibly indefinitely, to prevent sudden thrombosis (clotting) of the stent.
Research continues on the use of combined therapy — thrombolysis for immediate clot dissolving followed by angioplasty for more definitive treatment. Our improved understanding of coronary disease has opened exciting new opportunities in prevention and treatment. Hopefully, options will continue to expand as research is translated into further clinical progress.
This article first appeared in the November/December 2006 issue of Heart & Health Reports. For a subscription, call 1-877-HEART-12.
Reviewed by Francine Kaufman, M.D., 04/08
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