After a Heart Attack, All Clogged Arteries Should Be Repaired, Researchers Say

Healthline: Health News Article

June 2020

Surgeons are being urged to clear out all clogged arteries during surgery after a heart attack.

• About half of people who have a heart attack have more than one clogged artery.
• In a new study, researchers recommend that surgeons fix all clogged arteries they find in a person after a heart attack.
• Some experts are urging this become standard practice in heart attack aftercare.
• Others say the additional surgery isn’t always the best course of action.

During surgery after a heart attack, it may be preferable to not only fix the clogged artery that caused the attack, but all the other clogged arteries doctors find while they’re in there. That’s what a new study is suggesting.

About half of people who have a heart attack have clogged arteries beyond the primary culprit of their heart attack, found a research team led by scientists at McMaster University in Canada.

Fixing these additional clogs with stents during surgery led to a 26 percent decrease in heart attack recurrence and death, according to the results of the randomized study of more than 4,000 participants that included the participation of 130 hospitals in 31 countries.

The findings were published in the New England Journal of Medicine.

“This study clearly showed that there is long-term benefit in preventing serious heart-related events by clearing all of the arteries,” Dr. Shamir R. Mehta, a study co-author and a senior scientist at the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences, said in a press release.

“There was also no major downside to additional procedures.”

“These results are not surprising, as smaller trials taken together suggested a possible benefit but did not prove it,” Dr. Robert A. Harrington, president of the American Heart Association and Chair of Medicine at Stanford University in California, told Healthline.

“[The recent study] enrolled more patients than [earlier] small trials, thus providing more robust set of evidence to support the complete revascularization strategy,” he said.

Harrington also praises the study’s design and intent, seeking to refine and improve existing practice.

“We need more trials like this that are addressing common clinical scenarios but are not testing new drugs or devices,” he said.

The heart of the matter

So, should this practice become standard care?

It helps to know a little bit about how arteries get clogged and heart attacks happen in the first place.

Plaque build-up in the arteries, known as atherosclerosis, is one of the leading causes of heart attacks; though far from the only one.

And to some degree, even if you employ clean living and a heart-healthy diet, plaque build-up is inevitable.

“We have 100,000 heartbeats a day, which creates quite a bit of wear and tear on the inside of arteries,” Dr. Joshua Yamamoto, a cardiologist and author of “You Can Prevent a Stroke,” told Healthline.

“Our body naturally heals this internal injury, and we grow plaque in our arteries. What we commonly think of as risk factors for heart disease are truly just the things that accelerate the natural aging of our arteries,” he said.

Those risk factors include diabetes, smoking, high cholesterol, and high blood pressure.

“Ultimately, our genetics and time will produce some degree of plaque in everyone,” Yamamoto said.

As plaque grows in the arteries over time, some crack or rupture, forming a clot at the site of the injury, even if that plaque isn’t big enough to block blood flow in the artery. And what is a blood clot forming on a cracked coronary artery plaque?

“A heart attack,” Yamamoto said.

Stent Intent

Given the study’s findings, fixing all clogged arteries at once sounds like a logical path forward.

However, some experts suggest we should pause before defaulting to this practice 100 percent of the time.

“These findings may seem obvious. That is, why wait when you can fix something now?

However, it is important to note that not all blockages need to be fixed,” Yamamoto said.

“In fact, in someone who is stable — that is, not in the middle of a heart attack — stenting open blockages is often less important than finding the right medications to keep the blood flowing and protect the heart.

“Stenting an artery is not ‘free.’ The more arteries you fix, the more potential for complication. Yet, there is the undeniable reality that some blockages will create problems in the future. That is, you can pay now or pay later,” Yamamoto said.

Speedier decision-making

Fixing multiple clogged arteries during the surgery after a heart attack, while not standard practice, has been making its way through the medical community. This study may help push that practice further into recommended care.

“At present, guidelines dictate to do functional heart studies to assess heart muscle at jeopardy before fixing them. This study just fixed them,” Dr. Sanjiv Patel, a cardiologist at MemorialCare Heart & Vascular Institute at Orange Coast Medical Center in California, told Healthline.

“So, this study gives us support for fixing the remaining arteries without performing a more functional stress test.”

“I do not think there are any concerns with making this practice standard,” Dr. Christopher Sarnoski, interventional cardiologist at St. Luke’s University Health Network in Pennsylvania, told Healthline.

“We will wait and see what the revascularization society guidelines do with this study. I anticipate this to be upgraded with this trial.”

But even with a total cleaning out of arterial clogs, people should remain vigilant about their heart health going forward.

“You do not cure blocked arteries, you manage them,” Yamamoto said.

“When you need a stent, even in an emergency, it is important to think of yourself as a whole and to think of the future. If a blockage represents a possible future threat, it may be worth opening now. But remember, you are never done,” Yamamoto said.

“You can restore blood flow in a completely blocked artery, but you must always be mindful of the health of the rest of your arteries.

There is a lifetime of care, maintenance, and attention to detail to make sure that you remain on the best medications for your needs,” he said.

Surgical Interventions