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 requires emergency treatment. Treatment for unstable angina involves hospitalization with medications to stabilize your condition. Many people with unstable angina will require a procedure called angioplasty (also known as percutaneous coronary intervention), usually combined with the placement of a small metal tube called a stent. In some cases of unstable angina, heart surgery (coronary artery bypass) is needed.
But doctors have been debating which treatment for chronic stable angina works best. Some doctors think angioplasty is the best treatment option. Others believe taking medications for angina may be just as effective for some people 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 pain, discomfort or pressure in the chest, and doctors usually describe it as chronic stable angina or unstable angina.
- Chronic stable angina is a form of chest discomfort that happens when your heart is working hard and needs more oxygen, such as during exercise. The pain goes away when you rest. In chronic stable angina, the pattern of chest discomfort is consistent (thus, the term "stable") as far as how much physical exertion will trigger it. Your narrowed arteries can be the cause of this form of angina. If you have chronic stable angina, you may need to decide whether to use 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 either the new onset of angina or a change in your usual pattern of chest pain or discomfort (getting worse, lasting longer, or not being relieved with rest or use of medications). Unstable angina is dangerous and a warning sign of a heart attack. If your angina is unstable, seek urgent medical care. You may need hospitalization, adjustment of medications and 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
During an angioplasty (AN-jee-o-plas-tee), your doctor inserts a tiny balloon in your narrowed artery through a catheter that's placed in an artery, typically in your groin. 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 bare metal, while others are coated with medications to help keep your artery open (drug-eluting stents).
Angioplasty and stenting involve some risk. There's a risk of blockages re-forming after a stent is implanted, risk of a blood clot forming in the stent, as well as additional risks — albeit small — including the risk of having a heart attack, stroke, or life-threatening bleeding during or after the procedure. You should consider that even if you have a stent placed, you'll need to take aspirin for the rest of your life. You'll also need to take additional medications to prevent blood clots, usually for at least one year.
You'll probably remain hospitalized for at least a day while your heart is monitored and your vital signs are checked frequently. 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 open-heart surgery and has had good results.
If you have stable angina, you may be able to treat it with medications and lifestyle changes alone, meaning you may not need 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 sublingual nitroglycerin tablets, which 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, reducing blood pressure and reducing the workload on your heart. 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. Statins also may help reduce inflammation in your blood vessels to lessen the chance of a heart attack.
- 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). Ranolazine, an anti-angina medication, may be prescribed 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. 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. The Mediterranean diet may be especially beneficial and includes plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts.
- High cholesterol. Know your cholesterol numbers and ask your doctor if you've optimized them to the recommended levels.
- 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?
Your medical condition will determine whether having angioplasty and stenting or taking medications will work better for you. Talk to your doctor about which angina treatment is best for your situation. Consider this:
- People who have angioplasty and stenting first may feel better quicker. For example, their chest pain may decrease quicker than those who just take medication. However, some studies suggest that after a few years those who only take medication may have the same level of pain relief (less chest pain) as those who had angioplasty and stenting.
- People who take only medications for angina may not feel better as quickly, but medications require no recovery time and are less expensive than angioplasty and stenting. If you choose to take medications to treat your angina, it's important that you take them exactly as your doctor says so that you get the most benefit.
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.