Routine angioplasty after heart attack?

Question

Angioplasty is a commonly performed procedure (with some risk) to open clogged arteries supplying blood to the heart. But is angioplasty always needed if a person has suffered a heart attack in the past (recent or remote)? Thanks for your insight.

Answer 1

There are many circumstances in which angioplasty would not be performed. First, let's look at when it is performed:

Clinical indications for PCI [Percutaneous coronary intervention, or angioplasty] include the following:

Acute ST-elevation myocardial infarction (STEMI)
Non–ST-elevation acute coronary syndrome (NSTE-ACS)
Unstable angina
Stable angina
Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope)
High risk stress test findings

http://emedicine.medscape.com/article/161446-overview

A heart attack in the past isn't likely to meet any of those indications unless it's causing symptoms now such as angina or anginal equivalents. Generally, once ischemia (reduced blood flow) has killed heart tissue, reopening the artery with angioplasty won't accomplish anything. The tissue is dead and can't be revived. This last point is made in the same link as above. Emphasis is mine.

In an asymptomatic or mildly symptomatic patient, objective evidence of a moderate to large area of viable myocardium or moderate to severe ischemia on noninvasive testing is an indication for PCI. Angiographic indications include hemodynamically significant lesions in vessels serving viable myocardium (vessel diameter >1.5 mm).

Angioplasty also has a number of contraindications when it won't be performed even when the heart attack is ongoing. These include:

Clinical contraindications for PCI include intolerance of long-term antiplatelet therapy or the presence of any significant comorbid conditions that severely limit the lifespan of the patient (this is a relative contraindication).

Relative angiographic contraindications include the following:

Arteries <1.5 mm in diameter
Diffusely diseased saphenous vein grafts
Other coronary anatomy not amenable to PCI

[ibid., http://emedicine.medscape.com/article/161446-overview]

A lot of this is complicated language understood mainly only by cardiologists, but it boils down to saying that angioplasty will be performed only when it can save heart muscle from dying or when it can relieve chest pain or other symptoms, when the procedure is physically possible (eg, the arteries are large enough), and when it has a practical chance of extending the patient's life (eg, a terminal patient with days or weeks to live probably would not benefit from angioplasty).