Stents aren’t always the only option
By Eva Briggs, MD
Often when people hear the diagnosis of coronary artery disease, they assume that it will and should be treated with stents or bypass surgery.
But for many, perhaps most, the treatment of choice to prevent a heart attack is medicine, called optimal medical therapy.
Why should this be so? It seems like a simple plumbing problem. An artery is blocked, so shouldn’t it be cleaned out like a clogged drain?
Your heart has about 60 centimeter of large arteries and another 60 centimeters of smaller arteries. That’s a total of almost four feet!
A stent measures only one centimeter long. An area that appears narrowed on a study such as a cardiac catheterization may not be the site of a future heart-attack causing blockage. Most blockages happen when plaque lining a coronary artery breaks off and disrupts blood flow. Placement of a stent still leaves large lengths of diseased heart arteries untreated.
There are three main groups of medicines used to treat coronary artery disease. Blood thinners reduce the likelihood that blood will clot. Beta blockers slow the heart rate and lower blood pressure to reduce the heart’s work. Lipid lowering drugs reduce cholesterol which forms plaque in the lining of arteries.
The best studied blood thinner in heart disease is aspirin. For most people one baby aspirin (81 mg) is effective. This low dose poses less risk of unwanted bleeding such as from the gastrointestinal tract. For patients without heart disease, daily aspirin is usually not recommended to prevent heart attack because the risks outweigh any benefit.
Clopidogrel is a blood thinner that works as well as aspirin and is recommended for patients who have a stent. In some special circumstances, patients with stents may be prescribed dual antiplatelet therapy: both aspirin and clopidogrel.
Beta blockers are the drug of choice for angina (chest pain caused by decreased blood flow to the heart muscle.) They also improve survival when given during the first three years after a heart attack.
The preferred lipid lowering drugs are statins, such as simvastatin or atorvastatin. When I started practice, doctors tried increase the dose until the patient’s cholesterol numbers dropped to a certain level. Now the recommendation is to prescribe a recommended dose of these drugs. They appear to have an effect to decrease the chance that plaque in the arteries will rupture, independent of lowering the cholesterol. Another lipid lowering drug is niacin, which has been touted as a natural alternative. Unfortunately, it does not improve outcomes but does have many side effects, such as flushing. Fibrates are a class of drugs that do lower the risk of heart events but not the risk of stroke or the risk of death from cardiovascular disease. These drugs are beneficial for patients who can’t tolerate statins.
Nitroglycerin relieves angina pain quickly. It loses its potency once the vial is opened. If it doesn’t tingle when placed under the tongue, it’s no longer any good.
Heart patients should avoid NSAIDs, a group of pain-relieving medicines that increase the risk of heart attack. Ibuprofen and naproxen are two NSAIDs available over the counter. They should be limited to short-term use for pain not helped by acetaminophen.
