Factors that affect the choice of treatment in coronary artery disease

Treatment of coronary artery disease depends on a number of factors, along with your personal preferences and general health status.

Think about the following when you make decisions about your treatment.

How severe is the chest pain (angina), and will it respond to medication?

• In most cases, mild, ongoing, stable angina can be controlled using medication alone.
• Ongoing, stable angina that does not respond well to medication is considered severe and may require further evaluation and treatment.
• Unstable angina means that a heart attack may soon occur and that angioplasty or surgery may be needed.

What are the results of testing (stress EKG test, stress echocardiography, thallium scan) so far?

These tests measure how the heart responds to increased oxygen demand (stress test) and how effectively the heart pumps blood, which may help determine what treatment would be most effective.

The following test results suggest that there is adequate blood flow to the heart muscle and that medication may be enough to control symptoms. Surgery or angioplasty with stenting may be an option but may offer no additional benefit over medication and may involve more risk.

• Exercise stress test results are normal (or mildly abnormal), and the person can exercise well.
• The function of the left ventricle is normal (ejection fraction is greater than 50%).
• Thallium scan results show that blood to the heart muscle is normal or mildly abnormal (no cold spots or just a single, small cold spot).

The following findings suggest that the heart muscle is not getting enough blood or oxygen. Treatment may be needed to prevent permanent heart muscle damage and reduced heart function.

• Exercise stress test results are abnormal (especially if the person cannot exercise very long).
• The function of the left ventricle is reduced.
• Thallium scan shows one or more large areas of heart muscle that are not getting enough blood (cold spots).

If test results show that large areas of the heart muscle have already been permanently damaged, surgery or angioplasty with stenting to restore blood flow may not be needed or helpful.

An important factor to consider when choosing treatment is whether there is blockage in the left main coronary artery, which supplies blood to the main pumping chamber of the heart (left ventricle).

• Significant blockage in the left main coronary artery usually requires surgery. Bypass surgery (instead of angioplasty) is needed in most cases.
• If 2 to 3 heart arteries are blocked, the type of treatment will depend on the location and severity of the blockages, how they are affecting heart function, and how severe a person's symptoms are.
• If only one artery is blocked (other than the left main artery), medication or angioplasty is most often used.

What are your personal choices about treatment?

Another important consideration is your personal choice. People who can get information from their doctors about the risks and benefits of their treatment options are able to make better decisions.

Some people may feel intimidated or afraid to question their doctor. However, it's very important to understand why your doctor is recommending a certain treatment and the risks and benefits of that treatment.

Other factors that affect the decision include:

• Age. Older people, especially those with other long-term health problems, are at increased risk for surgical complications.
• Health status. People with other lifelong health conditions (such as diabetes or lung or kidney disease), those who have impaired mental function, and those whose nutritional status is poor also have a higher risk of surgical complications.
• Occupational status. People whose work involves public safety or responsibility for others' lives may be more likely to get surgery because it more rapidly lowers their risk of heart attack than medical treatment, thereby allowing them to resume their work safely.