Updated October 04, 2014.
Written or reviewed by a board-certified physician. See About.com's Medical Review Board.
Question: The Complicated Choices In Treating CAD
Can you share your thoughts about my father's CAD? My father, age 59, has angina and had a stress test that suggests CAD, and now is scheduled for cath. My father is a long-time smoker with lung disease. He's overweight and has diabetes, arthritis and other problems. The cardiologist is planning to put stents in if the cath shows CAD.
But I've read that drug-eluting stents have their own problems, and I don't know if they are are a good idea for him. What about bypass surgery or medicines?
I'm scared that the cure may kill the patient. Can you help?
Answer: I can't give specific medical advice on-line, but I hope these general comments might help.
CAD is a chronic, progressive disorder. Treating it with stents or bypass surgery will relieve partial blockages (at least temporarily), but does not make the underlying problem go away. The underlying disease process (atherosclerosis) continues to progress. This means that whatever anti-blockage treatment one chooses, more blockages are likely in the future -- EXCEPT, in many cases, where people adopt aggressive, Manhattan-project-like risk factor control. That is, where they take every step the can to arrest the progression of atherosclerosis.
The good news in your father's case is that there is ample opportunity for risk factor modification. He's got smoking cessation, hypertension control, cholesterol control, weight loss (to the point that his type II diabetes goes away), exercise, and diet. To really make a difference, these have to be undertaken with full focus and intensity, from now on, all the time, no exceptions.
Of course this will fundamentally change the way he lives, and forever.
But then, so will his CAD.
Deciding on medical therapy vs. stent vs. bypass surgery is often difficult. As a general rule, stenting and bypass surgery have not been shown to reduce the risk of heart attack or death in patients with stable angina, but they do nicely control the angina itself. There are some situations where bypass surgery (and probably stenting) can prolong life in patients with stable angina, namely, if there is a significant blockage in the left main coronary artery, or if there is significant blockage in each of the the three main coronary arteries. Doing a catheterization to see if either of these conditions is present is a reasonable idea.
Having a drug-eluting stent placed carries with it many considerations, as you have said, including limiting NSAIDS and some drugs for gastrointestinal disorders, but more importantly, a perhaps life-long need to take Plavix. Anyone taking Plavix cannot have surgery, and cardiologists often forbid their stent patients to stop Plavix for even a few days to enable surgery, leaving patients who need surgery between a rock and a hard place. (Read more about the risks of stopping Plavix here.) Before getting an elective stent one needs to nail down the cardiologist on how he/she plans to allow necessary surgery in the future.
(Emergency stenting, which is done during an acute heart attack, is a different matter. Here, stenting immediately can prolong life, and because time is of the essence there's almost never an opportunity to discuss the all pros and cons ahead of time. The patient comes in with a life-threatening emergency, stuff happens, and the patient is left to deal with the consequences of treatment.)
Also, please keep in mind that acute heart attacks and other forms of acute coronary syndrome are caused by the sudden rupture of plaques and the resultant formation of an occluding blood clot. The rupture may occur at the site of "significant blockages," but actually more often occur at plaques that are not causing significant blockage just prior to rupture. The art of preventing heart attacks is the art of preventing plaque rupture, and not the art of reducing blockages. Preventing plaque rupture relies on aggressive lifestyle changes (there it is again), and medications (like statins) to stablize plaques, and other medications (like aspirin) to reduce platelet stickiness.
In your father's case it is especially critical to stop smoking immediately, since the combustion products from tobacco are a powerful inducer of plaque rupture. That acute risk caused by tobacco is greatly diminished within 24 to 48 hours after the last smoke. Also, lipids, hypertension, poor vascular tone (from overweight, hypertension, and lack of exercise) will increase the likelihood of plaque rupture, so it is critical to get all of these under control as well.
In my view, people with CAD would do better if they developed the same attitude many patients develop when they are told they have cancer. That is, they realize they are in a fight for their life, and they drop all other considerations and focus -- entirely -- on whatever nasty measures they must endure to give themselves the best chance of surviving. Their attitudes and their lives completely change, and as a result they become much more likely to regain their health. Cardiologists (who all too often transmit the idea that there's a blockage, I fixed it, you're cured) are, in my opinion, culpable in not fostering the correct attitude among their patients. It's not a battle, it's a war, and wars entail lots of tough battles, one after the other. You can do a lot to improve your odds of winning that war. Fixing blockages is one possible tactic. But it's not a strategy.
It's too late for your father to gain from this last piece advice, but other readers ought to take heed: Once you develop CAD you are embarked on a life-long, chronic disease process that never goes away. In most cases, choosing among the therapies simply means choosing one type of chronic management problem over another. You will never again be free of drugs, doctors, and the medical ramifications of everything you do and don't do. Just look at the dilemma in which this correspondent's father finds himself, and he's just getting started with the process.
So if there is still time, do everything in your power NOW to prevent CAD.
Sources:
Fraker TD, Fihn SD, on behalf of the 2002 Chronic Stable Angina Writing Committee. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina. J Am Coll Cardiol 2007; 50:2264. Available at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.08.002