Do Angioplasty and Stents Improve Survival?

Studies expose limitations of the popular heart procedure

Angioplasty, computer artwork.

Shubhangi Ganeshrao Kene / Getty Images

If you have been diagnosed with coronary artery disease (CAD), you may be presented with the option of a procedure known as a percutaneous coronary intervention (PCI). PCI is comprised of two different techniques:

  • Angioplasty, in which a tube is threaded into an artery and inflated to widen the vessel and increase blood flow
  • Stenting, the insertion of a small mesh tube that holds the vessel open and prevents the blockage from re-forming

While the procedure is relatively straightforward and commonly performed, it has its limitations and may not be appropriate for everyone.

Indications

Percutaneous coronary intervention is a non-surgical procedure used to treat stenosis (narrowing) of the coronary arteries in people with CAD. It has different indications for use as well as different aims and outcomes.

PCI can be used in emergencies to treat acute myocardial infarction (heart attack), especially if there is evidence of heart damage on an electrocardiogram (ECG). The most common form is an ST-segment elevation myocardial infarction (STEMI), in which the obstruction of blood flow is abrupt and profound. In this case, the procedure is referred to as a primary PCI.

PCI may also be used in less severe cases—such as a non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina—if there is a risk of additional, more serious events.

PCI is sometimes used electively in people with stable angina if the symptoms (chest pains, chest pressure) are difficult to control. In such cases, a PCI may provide temporary relief but will not cure the underlying condition.

Limitations

Percutaneous coronary intervention is appropriate for the treatment of certain cardiac events and less appropriate for others. It is not considered a "cure-all" for arterial stenosis or an inherently "better" option for treatment compared to optimal medical therapy (OMT).

In fact, a number of studies have shown that OMT—consisting of diuretics, beta-blockers, calcium channel blockers, nitrates, and the aggressive control of blood pressure and cholesterol—can be just effective as PCI in treating certain forms of CAD. This was evidenced in part by a landmark study dubbed the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial.

Published in the New England Journal of Medicine in 2007, the COURAGE trial involved 2,287 adults with stable CAD who were provided either OMT or a combination of PCI and OMT. At the end of the five-year study, the researchers found that people provided OMT had no greater risk of heart attack or death than those offered PCI/OMT. Moreover, PCI was no better at relieving angina symptoms than OMT.

Interpreting the Findings

A follow-up study conducted in 2015 further confirmed the results. The researchers found that, when used in people with stable coronary disease, the procedure itself often undermined its own benefits in three ways:

  • PCI tends to injure the artery wall and increase the risk of secondary obstruction. In fact, 21% of the PCI group required another stent within six months, while 60% of the treated vessels required re-stenting.
  • PCI is associated with a greater risk of postoperative bleeding, heart attacks, and stroke in people with stable CAD compared to no treatment.
  • People who undergo PCI tend to return to the dietary habits that led to CAD in the first place (including the excessive consumption of red meat and unhealthy fats).

Studies have also shown that fewer than 45% of patients with CAD undergo stress testing prior to an elective PCI, suggesting that other modifiable risk factors (such as diet and exercise) have not been addressed.

Benefits

The COURAGE studies were important in not only describing the limitations of PCI but defining where PCI is appropriate, namely in the treatment of acute coronary syndrome (ACS). ACS is the term used to describe the three forms of CAD in which blood flow to the heart is blocked either partially or completely:

  • STEMI, in which the blockage is severe and more apt to cause damage
  • NSTEMI, in which the blockage is partial or temporary
  • Unstable angina, in which the partial obstruction of a coronary artery causes chest pain and other symptoms

PCI has its appropriate use in each of these conditions.

STEMI

In people with STEMI, PCI significantly reduces the risk of mortality (death) and morbidity (illness) compared to OMT. If performed within 12 to 72 hours of the first appearance of symptoms, PCI can also reduce the extent and severity of heart muscle damage.

A 2015 study from France concluded that PCI performed within 24 hours of a STEMI event translates to a five-year survival rate of 85% compared to only 59% for those who receive no treatment.

NSTEMI and Unstable Angina

PCI can also benefit people with NSTEMI in whom the procedure can improve early survival rates if performed within 24 hours. According to a 2018 study involving 6,746 adults with NSTEMI, early PCI reduced the risk of death during the first 28 days by as much as 58% compared to delayed treatment. Long-term quality of life measures were also improved.

PCI may offer similar benefits to people with unstable angina, although there remains considerable debate on when treatment is needed. Even with respect to NSTEMI, there is no clear-cut line by which treatment is either indicated or avoided.

A 2016 review of studies published in the Cochrane Database of Systematic Reviews concluded that the use of PCI in people with NSTEMI lowers the risk of a heart attack over the next three to five years but also double the risk of a heart attack during or soon after the procedure.

Careful consideration is needed in borderline cases where the risks may outweigh the benefits. This is especially true with multivessel blockages in which coronary artery bypass grafting (CABG) is considered superior to PCI both in efficacy and long-term survival.

A Word From Verywell

In response to the COURAGE trial and other related studies, the American Heart Association (AHA) and American College of Cardiology (ACC) issued updated guidelines outlining the appropriate use of PCI in people with heart disease.

In people with stable CAD, the guidelines stress lifestyle changes and the appropriate use of medications in first-line treatment. This includes a heart-healthy diet, routine exercise, smoking cessation, and adherence to daily drug-taking.

For those with NSTEMI and unstable angina, clinical insight is needed to determine if other options are more appropriate, including CABG or OMT.

Whatever the application, PCI should not be considered a "quick fix" but one for which the benefits, risks, and limitations should be weighed with a qualified cardiologist or cardiac surgeon.

Was this page helpful?

Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Petroni T, Zaman A, Georges JL, et al. Primary percutaneous coronary intervention for ST-elevation myocardial infarction in nonagenarians. Heart. 2016;102:1648-54. doi:10.1136/heartjnl-2015-308905

  2. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426. doi:10.1161/CIR.0000000000000134

  3. Boden WE, O'Rurke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-16. doi:10.1056/NEJMoa070829

  4. Borden WB, Redberg RF, Mushlin AI, Dai D, Kaltenbach LA, Spertus JA. Patterns and intensity of medical therapy in patients undergoing percutaneous coronary interventionJAMA. 2011;305(18):1882-9. doi:10.1001/jama.2011.601

  5. Nepper-Christensen L, Lønborg J, Høfsten DE, et al. Benefit From reperfusion with primary percutaneous coronary intervention beyond 12 hours of symptom duration in patients with ST-segment-elevation myocardial infarction. Circ Cardiovasc Interv. 2018;11(9):e006842. doi:10.1161/CIRCINTERVENTIONS.118.006842

  6. Danchin N, Puymirat E, Steg PG, et al. Five-year survival in patients with ST-segment-elevation myocardial infarction according to modalities of reperfusion therapy: the French registry on acute ST-elevation and non-ST-elevation myocardial infarction (FAST-MI) 2005 cohort. Circulation. 2014;129(16):1629-36. doi:10.1161/CIRCULATIONAHA.113.005874

  7. Arora S, Matsushita K, Qamar A, Stacey RB, Caughey MC. Early versus late percutaneous revascularization in patients hospitalized with non-ST-segment elevation myocardial infarction: the atherosclerosis risk in communities surveillance study. Catheter Cardiovasc Interv. 2018;91(2):253-9. doi:10.1002/ccd.27156

  8. Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2010;(3):CD004815. doi:10.1002/14651858.CD004815.pub3

  9. Spadaccio C, Benedetto U. Coronary artery bypass grafting (CABG) percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? - a review of the evidences on coronary artery disease. Ann Cardiothorac Surg. 2018;7(4):506-15. doi:10.21037/acs.2018.05.17

  10. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124(23):e574-651. doi:10.1161/CIR.0b013e31823ba622