General Medical · Health

Coronary Artery Disease in Women: What Are the Options When an Artery Is Blocked?

Revascularizion, as alluded to above, is necessary in most women and men with an ACS. In stable coronary artery blockage, however, medical management has a crucial role to play, and revascularization should be used selectively.  The COURAGE trial, whose results were announced in 2007, demonstrated very similar outcomes in patients treated with optimal medical management or invasive revascularization. (The trial was named COURAGE to denote the courage of the investigators who randomly allocated a large group of patients with severe coronary obstruction but stable symptoms to either revascularization or optimal medical therapy.)

The COURAGE  trialists adhered to guidelines that directed the use of optimal medical therapy—therapy that includes the use of aspirin (to help prevent thrombus from adhering to plaque) and beta blockers (medicines that oppose the effect of adrenaline, reducing the heart rate). As a consequence, the heart’s demand for oxygenated blood is better aligned with diminished blood flow through a partial occlusion. Statin therapy is a cornerstone of optimal medical therapy.  By lowering the bad cholesterol (LDL) as much as 60 percent, cholesterol is leached out of the atherosclerotic plaque, reducing its volume and also reducing inflammation of the cap created in part by sharp cholesterol crystals.  The plaque becomes stabilized, smaller, with a thicker cap, thus reducing the risk of an ACS from plaque erosion or rupture in a stable patient. There is evidence that women do not receive this critical therapy as often as men do, despite a similar—or, in some studies, potentially greater—impact.

In spite of the rosy picture painted by the COURAGE trial and the surrounding media stir, there are many reasons that, for a patient with stable symptoms, a physician may recommend—or a patient may choose to undergo—revascularization.  In almost all studies, opening the artery with PCI or CABG is associated with better symptoms relief and quality of life.  In the oft-quoted COURAGE study, one third of the patients had intolerable symptoms and chose PCI.  Beta blockers and other medications used to diminish anginal symptoms have side effects, and a patient may choose revascularization to improve quality of life.  A single revascularization to restore blood flow, coupled with healthy lifestyle changes and the continued use of a statin, can be life-changing, eliminating any manifestations of CAD for years, or even indefinitely.

Next page: Utilizing Stress Tests

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