Angioplasty Now Standard Care for Heart Attacks

For years, two major treatments were used to treat an acute heart attack: thrombolytics (clot-dissolving agents) such as streptokinase and tPA (tissue plasminogen activator), and angioplasty - a surgical technique that opens clogged arteries to restore blood flow to the heart.

But study after study has shown angioplasty to be superior to clot-busters in effectively reducing repeated cardiac events and death from cardiovascular-related problems. In fact, the evidence in favor of angioplasty is so strong that thrombolytics are now generally used only when heart attack victims must be treated at facilities that do not have catheterization labs or surgeons available to perform an angioplasty.

"Simply put, there's a greater likelihood of getting the blood vessel open and keeping it open with angioplasty," said David L. Rutlen, MD, FACP, FACC, Medical College Professor and Chief of Cardiovascular Medicine. Dr. Rutlen is Director of the Froedtert & The Medical College of Wisconsin Cardiovascular Center.

Opening Clogged Arteries
Coronary angioplasty is a medical procedure used to restore blood flow through a narrowed or blocked artery in the heart. The arteries of the heart (the coronary arteries) can become narrowed and blocked due to buildup of a material called plaque on their inner walls. This narrowing reduces the flow of blood through the artery and can lead, over time, to coronary artery disease and heart attack.

In angioplasty, a thin tube with a balloon or other device on the end is first threaded through a blood vessel in the arm or groin (upper thigh) up to the site of a narrowing or blockage in a coronary artery. Once in place, the balloon is then inflated to push the plaque outward against the wall of the artery, widening the artery and restoring the flow of blood through it.

Angioplasty Superior for Heart Attack
For a heart attack, angioplasty is clearly a better treatment than thrombolytics, Dr. Rutlen said. The first long-term study of outcomes for angioplasty patients compared to those treated with the clot-buster streptokinase was published in November 1999 in the New England Journal of Medicine.

That research showed that angioplasty reduced the likelihood of a second heart attack, cut by more than half the number of patients who died of cardiovascular-related causes within five years, and improved heart-pumping function. Subsequent research and "metastudy" data compilation and analysis have been in keeping with the earlier findings, Dr. Rutlen said.

Angioplasty not only saves more lives than thrombolytic drugs, research indicates that total medical costs are lower when angioplasty is used. Hundreds of thousands of angioplasties are performed each year in the US, where heart attacks strike well more than a million people annually, killing about one-third of them.

"I don't think there's much enthusiasm among the public now for considering thrombolytics for acute heart attack," said Dr. Rutlen. "The only time you'd really consider using thrombolytics for heart attack is where you don't have a cath lab available where you can do a direct (surgical) intervention.

"If you're off in rural Wisconsin somewhere too far from a cath lab, then thrombolytics clearly would be the best option," said Dr. Rutlen. "Many smaller communities do have interventional facilities available, though. For example, Manitowoc and Wausau aren't exactly rural, but they're smaller than a lot of cities in the state, yet they both have facilities for surgical intervention. In addition, helicopter and ambulance dispatch and transport systems have improved in recent years, enabling even rural heart attack victims to be taken to fully equipped facilities.

Of course, "the critical issue in treating heart attack is to get to a hospital right away. If that hospital has surgical intervention available they would do an angioplasty. If they don't have that intervention available, then they would use thrombolytics.

Thrombolytic Still Used for Stroke
The thrombolytic tPA is still widely used to good effect in treating stroke victims. When the stroke is ischemic (the most common kind, where bleeding is not present) and tPA is administered within three hours after symptoms start, long-term damage from the stroke can be greatly minimized. Thrombolytics halt a stroke by dissolving the blood clot, or thrombosis, that is blocking blood flow to the brain.

Dan Ullrich
HealthLink Contributing Writer

For more information on this topic, see the HealthLink article Stroke Program Provides Pioneering Treatment.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.