Hundreds of thousands of Americans each year are being needlessly rushed into costly, potentially dangerous heart tests and treatments--particularly angioplasty to open blocked arteries.

Research now shows that angioplasty saves lives only when done shortly after a heart attack. At other times it just relieves angina, or chest pain during exertion. And lifestyle changes--diet and exercise--plus medication are usually the best first treatment for angina; that’s a safer approach that can prolong life. Many experts worry that a third or more of all angioplasties in the U.S. are performed when other approaches, usually more conservative, would have been more appropriate.

That conclusion jibes with the latest understanding of heart disease: It’s now viewed as a pervasive process, affecting the entire web of coronary arteries, that can often be controlled or even reversed by noninvasive treatment. But many cardiologists still see the disease as a high-tech plumbing problem, involving isolated blockages that require angioplasty.

Undue enthusiasm for two recent technological advances has further fueled the overuse of angioplasty. One is CT coronary angiography, a highly publicized imaging test that for the first time can pinpoint artery blockages without invasive methods. Hospitals and doctors are promoting the test in direct-to-consumer ads.

The second advance involves drug-coated stents, cylindrical inserts that help maintain the opening created by angioplasty; they’re supposedly safer and more effective than older, bare-metal stents.

But many experts say the benefits of CT angiography are overblown and usually outweighed by the risks. And several studies published or presented in 2006 found that drug-coated stents pose unexpected dangers, possibly even increasing the long-term risk of heart attack.

This report will describe the new concept of heart disease and tell when cardiac imaging, angioplasty, and drug-coated stents are appropriate, and when other steps should be used instead.

In angioplasty, a tiny balloon is snaked through a small incision in the groin and up to a narrowed coronary artery; then it’s inflated to crush the plaque deposit that’s restricting blood flow and causing angina. Finally, a stent is almost always inserted to prevent renewed narrowing.

But diseased arteries typically contain additional plaque deposits too small and numerous to be treated with angioplasty. Researchers now know that the vast majority of heart attacks occur not when a large deposit blocks an artery but when inflammation, high blood pressure, or other factors cause a smaller, less-stable deposit to rupture, producing an artery-blocking blood clot.

“Preventing those small, vulnerable deposits from developing and bursting is the key to preventing heart attacks,” says Steven Nissen, M.D., president of the American College of Cardiology. “Neither angioplasty nor stenting accomplishes that,” Nissen says.

But some cardiologists still believe that all narrowings in the arteries must be treated with angioplasty even if there’s no angina.

Overconfidence in CT angiography and drug-coated stents has encouraged the overuse of angioplasty--and financial incentives have exacerbated the problem. For example, cardiology practices that buy the costly CT scanner may feel pressured to use it in marginal candidates, increasing the chance of needless angioplasties. Moreover, many doctors who perform either that test or traditional angiography also perform angioplasty--a highly lucrative procedure that becomes even more profitable when drug-coated stents are used. That linkage of the diagnostic and therapeutic procedures creates a possible incentive for doctors to do excessive testing to generate more angioplasties.

The net result: The number of angioplasties has tripled in the past decade or so. But that overuse may now be slowing as researchers question the value of CT angiography and coated stents.

CT angiography checks coronary arteries for narrowing and also measures the amount of calcium, a major component of plaque, in the artery walls. The scanner takes up to 64 virtually simultaneous images, which a computer reassembles to create a three-dimensional image.

But the test is seldom worthwhile, our medical consultants say. It’s often done to determine the need for angioplasty, but in asymptomatic people that treatment is rarely useful. CT testing in someone without angina might reveal severe blockages requiring bypass surgery, or prompt more-aggressive treatment of hypertension or high cholesterol. But those possible benefits are probably outweighed by the risk from radiation exposure, our medical consultants say. The newest CT scanner, for example, exposes you to 80 to 325 times the radiation from a standard chest X-ray, an amount that could cause death from cancer in 1 of every 2,000 people, some estimates indicate.

Instead, asymptomatic people who want more information about their coronary risk should learn their level of C-reactive protein, or CRP. That requires only a cheap blood test and gives crucial information about artery inflammation.

CT angiography has little value even in people with angina. They need standard angiography, usually preceded by a test that stresses the heart with exercise or drugs. While those procedures are longer and less comfortable than CT angiography, they’re still the gold standard for determining the extent of coronary disease. And they’re needed to rule out severe blockage that might require bypass surgery, even if you’ve taken the CT test.

If standard angiography reveals significant narrowing in the heart’s main artery or three other major arteries, bypass surgery is required to prevent an imminent heart attack. (The box at the end of this story, “Minimally invasive bypass,” describes the newer, less-invasive, most common version of that operation.) If there’s no such narrowing, people with angina should almost always start with lifestyle changes and medication, not angioplasty. The one possible exception: Total or near-total blockage of two or perhaps one major artery may warrant angioplasty.

Those noninvasive steps can frequently relieve angina and lengthen life, research suggests. For example, German scientists randomly assigned angina patients to either intensive daily exercise or angioplasty. After one year, angina relief was similar in both groups--but the exercisers had lower rates of heart attack, stroke, and hospitalization for worsening angina.

Other research shows that making additional lifestyle changes--notably stopping smoking, losing weight, cutting back on saturated fat and trans fat, and perhaps taming stress--can halt or even reverse the progression of coronary disease. Combining those measures with drugs and probably fish-oil supplements can further improve angina relief, heart-attack protection, or both.

But making those changes and managing the multiple medications can be hard. So ask your doctor for referrals to a nutritionist and physical therapist. And use the information in “Heart drugs, supplements,” to make sure you get the right medicines and take them properly.

If several months of lifestyle changes and medication don’t relieve angina, it’s time to consider angioplasty or possibly bypass. But you need to use caution.

Angioplasty can trigger a heart attack in 1 to 2 percent of patients. (Make sure the hospital has a bypass-surgery team available during the procedure.) Until the advent of drug-coated stents, about 25 percent of angioplasty patients within six months experienced renarrowing at the site caused by new plaque deposits, requiring a repeat procedure.

The new stents, now used in more than 80 percent of all insertions, are coated with a cocktail of medications that have slashed that renarrowing rate to less than 5 percent. But several studies now suggest that the risk of a potentially deadly blood clot at the site of a coated stent--but not a bare-metal one--unexpectedly rises after about a year, possibly increasing the risk of heart attack and death. Experts convened by the Food and Drug Administration in December 2006 to discuss the issue said it’s still uncertain whether that risk stems from doctors failing to prescribe the necessary anticlotting drugs after the procedure, patients failing to take those drugs, or cardiologists inserting the stents in inappropriate, high-risk patients. Meanwhile, heart patients, including those considering angioplasty, should heed the advice below.

In general, don’t bother with CT angiography.

Undergo standard stress testing and conventional angiography if you have angina. Asymptomatic individuals generally don’t need testing unless they are older and have a job affecting public safety, such as flying a plane, or are middle-aged or older, have multiple coronary risk factors, and are starting an exercise program.

If those tests confirm heart disease but rule out severe blockages requiring bypass surgery, start with lifestyle changes and medication to treat angina in most cases.

In general, agree to immediate angioplasty plus stenting only if you’ve just had a heart attack, or angina severely hampers your lifestyle. In other cases, first try medication and lifestyle changes for three to six months.

Drug-coated stents make the most sense for the relatively low-risk, best-studied group: individuals with one or possibly two uncomplicated plaque deposits who don’t have diabetes or kidney disease. In other cases, ask your cardiologist if bare-metal stents or bypass surgery would be better. And take anticlotting medications, usually aspirin and clopidogrel (Plavix and generic), for at least a year after any stent implantation.

Get bypass surgery if you have severe blockages or angina that doesn’t improve after angioplasty.

If you need invasive treatment, seek a cardiologist who performs at least 75 angioplasties or a cardiac surgeon who does at least 100 bypasses a year, and a hospital that does at least 400 angioplasties and 200 bypasses a year.

In the standard operation, the surgeon cuts open the chest, reroutes the blood through a heart-lung machine, stops the heart, grafts veins around the blockages, restarts the heart, and wires the chest back together. Patients usually spend four or five days in the hospital and recover fully in one to three months.

The new versions are far less traumatic, encouraging much faster recovery, though they’re appropriate only for certain patients. The most common approach, called MIDCAB, requires only a 3-inch incision and several small puncture sites. Using special tools, the surgeon immobilizes part of the heart long enough to implant one or two noncardiac vessels onto the front of the heart without stopping the heartbeat. Several studies suggest that the new operation costs less and poses less risk of major complications, notably stroke, kidney damage, and possibly mental impairment. But there’s still little long-term evidence.

Our consultants say the new bypass techniques are most likely to help people who clearly need bypass of one or two blocked arteries on the heart’s front but face a high risk of complications from the standard surgery. However, the technique is still riskier and more invasive than angioplasty, so it shouldn’t be done when that procedure is appropriate.

Heart drugs, supplements
Most people with heart disease need to take at least five drugs and probably one dietary supplement. For ACE inhibitors, beta-blockers, and statins, the specific drugs listed below were identified by Consumer Reports Best Buy Drugs as the best choice for people with existing heart disease. For details, including costs, risks, and precautions, see www.ConsumerReports.org/Health and click on Best Buy Drugs.
Drug	Purpose
Beta-blockers: Generic atenolol, metoprolol tartrate, nadolol, and propranolol	Prevent angina, lower blood pressure, and cut risk of second heart attack by reducing work of heart muscle.
Nitroglycerin: Generic	Stops angina attacks by relaxing blood vessels.
Statins: Generic lovastatin, generic simvastatin, or atorvastatin (Lipitor)	Reduce risk of heart attack and death by lowering cholesterol levels, stabilizing plaque deposits, and possibly reducing inflammation.
Angiotensin-converting enzyme (ACE) inhibitors: Generic benazepril, captopril, enalapril, and lisinopril as well as ramipril (Altace)	Reduce risk of heart attack by inhibiting blood clots, stabilizing plaque deposits, and relaxing blood vessels (which also lowers blood pressure).
Low-dose aspirin: Generic	Reduces heart-attack risk by inhibiting blood clots.
Omega-3 fatty acids: 1 gram a day, which is feasible only by taking fish-oil supplements	Reduce heart-attack risk by inhibiting blood clots and abnormal heart rhythms, and lowering blood pressure and triglycerides.