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Angina treatment: Stents, drugs, lifestyle changes — What's best?

Your doctor says your chest pain (angina) is caused by blockages in your heart arteries and that you need to get those blockages taken care of.

What are your options?

First, it's important to determine what type of angina you have. There are two main types of angina — chronic stable angina and unstable angina. Unstable angina is a serious situation and doctors agree that unstable angina requires emergency treatment. Treatment involves surgery or a procedure called angioplasty (also known as percutaneous coronary intervention), combined with the placement of a small metal tube called a stent

But doctors have been debating which treatment for chronic stable angina works best. Some doctors think angioplasty is the best treatment option. Other researchers believe taking medications for angina may be just as effective for some people to prevent heart attacks as undergoing angioplasty.

Making a decision on how to treat your angina can be difficult, but knowing the benefits and risks of stents and medications may help you decide.

Why are there different treatments for each type of angina?

Angina is chest pain, and doctors usually describe it as chronic stable angina or unstable angina:

• Chronic stable angina is a form of chest pain that happens when your heart is working harder and needs more oxygen, such as during exercise. The pain goes away when you rest. Your narrowed arteries can be the cause of this form of angina. If you have chronic stable angina, you may need to decide between angioplasty with stenting or medications as treatment. If the blockage causing chronic stable angina is severe, it's possible your doctor may recommend coronary bypass surgery, in which the blocked arteries are replaced with blood vessels grafted from another part of your body.
• Unstable angina is a change in your usual pattern of chest pain. It's chest pain that's getting worse or lasts longer or that doesn't get better with rest or use of medications. Unstable angina is dangerous and a warning sign of a heart attack. If your angina is unstable, then seek urgent medical care. You may need angioplasty with stents, even if your doctors find that you're not having a heart attack.

What are treatment options for chronic stable angina?

Angioplasty and stenting
Angioplasty (AN-je-o-plas-tee) involves temporarily inserting and expanding a tiny balloon at the site of your blockage to help widen a narrowed artery. Angioplasty is usually combined with implantation of a small metal coil called a stent in the clogged artery to help prop it open and decrease the chance of it narrowing again (restenosis).

During an angioplasty — also called a percutaneous coronary intervention (PCI) — your doctor inserts a tiny balloon into your narrowed artery. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open. Some stents are simply bare metal, while others are coated with medications to help keep your artery open (drug-eluting stents).

Angioplasty and stenting involves some risk. There's a small risk of blockages re-forming after a stent is implanted, as well as additional risks — albeit small — including the risk of having a heart attack during the procedure. Finally, inserting a stent is expensive, meaning you may want to factor the higher cost into your medical decision.

You'll probably remain hospitalized for at least a day while your heart is monitored and your vital signs are checked frequently. Your doctor will likely prescribe medications (anticoagulants and anti-platelet agents) to prevent blood clots. You should be able to return to work or your normal routine the week after angioplasty.

Many doctors consider angioplasty with stent placement to be a good angina treatment option for blocked arteries and chronic stable angina. That's because it's less invasive than is open-heart surgery and has had good results.

Medications
If you have stable angina, you can treat it with medical therapy and lifestyle changes, meaning you may not need to undergo angioplasty with stenting. Medications that can improve angina symptoms include:

• Aspirin. Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clotting may reduce your risk of a heart attack.
• Nitrates. Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, allowing more blood to flow to your heart muscle. You might take a nitrate when you have angina-related chest discomfort, before doing something that usually triggers angina (such as physical exertion), or on a long-term preventive basis. The most common form of nitrate used to treat angina is with nitroglycerin tablets that you put under your tongue.
• Beta blockers. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, your heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels relax and open up to improve blood flow, thus reducing or preventing angina.
• Statins. Statins are drugs used to lower blood cholesterol. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in the buildup of fats (plaques) in your artery walls, helping prevent further blockage in your blood vessels.
• Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina. Calcium channel blockers also slow your pulse and reduce the workload on your heart.
• Angiotensin-converting enzyme (ACE) inhibitors. These drugs help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that affects your cardiovascular system in numerous ways, including narrowing your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder.
• Ranolazine (Ranexa). This drug is used only when other anti-angina drugs haven't worked because it can cause a heart problem known as QT prolongation, which increases your risk of heart rhythm problems. It's used with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin.

If you try drug treatment and lifestyle changes and you still have symptoms that are limiting you, a stent may be the next step.

Lifestyle changes: Part of either treatment
Regardless of which angina treatment you choose, your doctor will recommend that you make lifestyle changes to further improve your angina. Because heart disease is often the underlying cause of most forms of angina, you can reduce or prevent angina by working on reducing your heart disease risk factors. These risk factors include:

• Smoking. If you smoke, stop.
• Poor diet. Eat a healthy diet with limited amounts of saturated fat, lots of whole grains, and many fruits and vegetables. Know your cholesterol numbers and ask your doctor if you've reduced it to the recommended level.
• Lack of physical activity. Talk to your doctor about starting a safe exercise plan. Because angina is often brought on by exertion, it's helpful to pace yourself and take rest breaks.
• Excess weight. If you're overweight, talk to your doctor about weight-loss options.
• Underlying conditions. Treat diseases or conditions that can increase your risk of angina, such as diabetes, high blood pressure and high blood cholesterol.
• Stress. Avoiding stress is easier said than done, but try to find ways to relax. Talk with your doctor about stress-reduction techniques.

So which angina treatment is better — angioplasty and stenting or medications?

In a 2007 study called the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, researchers found that in people with chronic stable angina, getting a stent didn't improve their chances of preventing a heart attack or dying. In other words, getting an angioplasty and stent combined with taking medications and making lifestyle changes didn't prevent any additional deaths or heart attacks compared with only taking medications and making lifestyle changes.

Talk to your doctor about which angina treatment is right for you. Consider this:

• People who have angioplasty and stenting first may have earlier and better symptom relief, such as reduced chest pain, than do people who just take medication. However, after five years, research has shown the chest pain relief was about the same between those who have angioplasty and stenting and those who only take medication.
• People who take only medications to relieve their angina may not have quick chest pain relief, but medications require no recovery time and are much less expensive than are angioplasty and stenting. If you choose to take medications to treat your angina, it's important that you take them exactly as your doctor instructs you so that you get the maximum benefit from your medications.

What if your angina treatment doesn't work?

If you try medication and lifestyle changes first, but they don't relieve your angina, angioplasty and stents may be another option. It might be reasonable to try more-conservative steps first — medication and lifestyle therapy — before considering a stent. Talk to your doctor if you're concerned that medications or stents aren't controlling your angina. Remember that with either treatment plan, lifestyle changes are important to improving your symptoms and overall health.