HEALTH MATTERS: A look at coronary artery disease and angina pectoris
Q. I have coronary artery disease, and the physician assistant who is my primary caregiver has repeatedly emphasized the importance of promptly going to the emergency department of our local hospital if I have prolonged chest discomfort. Why is it so important?
A. Chest pressure or tightness is the classic symptom that we see when the heart muscle itself isn't getting enough blood from the arteries that feed it. If this is because of just a narrowed artery and occurs with activity, the discomfort usually is relieved by resting.
We call this discomfort "angina pectoris." But when the discomfort is prolonged and continues even while at rest, this suggests that the artery has closed down completely and that a heart attack is in progress. Unless the artery is reopened, part of the heart will die because of inadequate blood flow. That's what a heart attack is. Our technical name for a heart attack -- myocardial infarction -- reflects this.
"Myocardial" means heart muscle and "infarction" means cell death caused by an inadequate blood supply. So it is critical to get the artery opened as quickly as possible using either a blood-clot-busting drug or a stent. One disturbing finding from a recent study, however, showed that while clinics and hospitals have gotten really good at treating patients quickly -- with about a 20 percent reduction in the time until treatment is given -- mortality remained unchanged over the four years of the study. This suggests that patients are still waiting too long before seeking medical attention, and in order to further lower the mortality associated with a heart attack, we need patients to come in sooner. So, please heed the excellent advice of your PA!
Q. I have high blood pressure, and my doctor found that I have a narrowed artery going to one kidney. Will I be able to get off my blood pressure medicines if they put in a stent to open up the narrowed artery?
A. Unfortunately, the answer is no, but some background may be helpful here. We have known for almost 80 years that narrowing of a kidney artery can produce high blood pressure because the affected kidney secretes an excessive amount of a hormone that raises blood pressure. Relieving the narrowing in experimental animals eliminates the attendant high blood pressure.
Since thickening and hardening of a kidney artery can narrow it and thus cause high blood pressure, it was hoped that fully opening up the artery with a stent (which is similar to but larger than the stent used in heart arteries) might reverse the high blood pressure. But a well-done recent trial that used stents in nearly 1,000 patients found no definitive benefit over a follow-up period of about 3½ years.
Patients treated with just medicine did as well as those who received medicine and a stent. And stenting didn't even reduce the risk of a progressive decline in kidney function, which is the other feared complication of a narrowed kidney artery in addition to high blood pressure. So the bottom line is clear -- you and most patients with similar conditions should not receive a kidney artery stent in the hope of eliminating high blood pressure, preventing progressive kidney failure, or reducing your risk of other blood vessel complications. Just keep taking your medicine to control your high blood pressure!
Wynne is vice president for health affairs at UND, dean of the School of Medicine and Health Sciences, and a professor of medicine. He is a cardiologist by training.
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