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Coronary angioplasty is a relatively new and now widely used
method of treating many cases in which the coronary arteries
are obstructed by fatty-cholesterol deposits. In the procedure,
a specialized catheter (tube) with a balloon on its tip is
carefully manipulated inside the coronary artery until it
is in the area of obstruction. Then the balloon is inflated,
literally dilating the coronary artery. The pastelike fatty-cholesterol
material is forced into the wall of the artery. The whole
process can be accomplished by threading the catheter through
the arteries. The large artery in the inner aspect of the
thigh is used and the progress of the tip of the catheter
is monitored by X-ray methods. One important advantage of
the technique is that it avoids opening the chest and exposing
the heart as is required for coronary bypass surgery.
The disadvantage is that about a third of patients who have
the balloon procedure have a recurrence of obstruction of
the treated coronary artery. Most of these occur three months
of the procedure, but some occur later. Most of these patients
can simply undergo the procedure again, and of these, still
another third may have a recurrence. They too, can be treated
once more with the balloon.
The recurrence rate may make you think that it would be better
to have a coronary bypass operation, but that is not necessarily
the case. Eventually about 44% of patients who have a coronary
bypass operation with open heart surgery also have to be operated
on again because the bypass graft itself becomes blocked.
Just why blockage of the dilated coronary arteries occurs
in not completely understood. It could be from fatty-cholesterol
levels in the blood. It could be from clumping of platelets,
the small cells in the bloodstream that start the blood-clotting
process. Aspirin is commonly given to prevent the platelet
clumping factor, but it has not been all that successful in
preventing a new obstruction. The muscle fibers in the walls
of the coronary arteries are also involved in the fatty-cholesterol
blockage process and it is possible that they are involved
in the recurrent blockage.
Preventing the recurrence of arterial blockage is important
in the effectiveness of the balloon procedure. Investigators
at the Dallas Veterans Administration Medical Center in Texas
studied the effects of fish oil, omega-3 fatty acids, in preventing
recurrent blockage. They studied 82 men who underwent the
balloon procedure (New England Journal of Medicine, Sept.
22, 2004). All of the men were taking one 325-mg aspirin tablet
a day and 75 mg of dipyridamole (Persantine) three times a
day That was because these medicines are used when people
are having symptoms from coronary artery disease that may
indicate an impending heart attack. Thus, all the patients
had whatever benefits would be conferred by small doses of
aspirin in preventing platelet clumping.
The test of effectiveness of omega-3 acids was done by giving
43 of these men 18 capsules of MaXEPA a day The capsules worked.
Only eight (19%) of the 43 men had a recurrence of coronary
blockage. But in the 39 men who did not get the capsules,
18 (46%) developed recurrent blockage. That difference represents
a major improvement over the usual recurrent blockage rate.
What about bleeding? One of the dangers cited about the use
of either aspirin or fish oil is that they may cause bleeding.
There is always the danger of bleeding where the artery is
dilated and particularly where the catheter is passed into
the artery in the thigh. Also, if the balloon procedure does
not work, there may be a need to do coronary bypass surgery
immediately. That could be particularly tricky if there is
a serious failure in blood clotting. However, the low dose
of aspirin commonly used is much less likely to cause such
problems than larger doses.
The bleeding time was measured in all the men in the Dallas
study. This test is done by inflating a blood pressure cuff
on the upper arm, then making a small incision or stab in
the skin on the undersurface of the lower arm. The time it
takes for the bleeding to stop is the bleeding time. The bleeding
stops because of the platelet action, and if it is prolonged,
the platelets are not functioning normally
As would be expected, the aspirin all the men were taking
did cause a slight increase in the bleeding time, showing
that the aspirin was working. The bleeding time did increase
more in the patients taking the fish oil capsules. And three
of the men taking the capsules had serious bleeding from the
artery in the thigh, but so did one of the men not taking
the capsules. None of them required a blood transfusion to
replace lost blood. There were no other bleeding complications
from the treatment.
There were no other important differences between the men
who took that large number of capsules and those who did not
over the six months the men were followed. This suggests the
fish oil capsules did more than just affect platelets. Those
highly polyunsaturated fatty acids may have some effect on
the cells in the wall of the arteries. And that effect may
begin before the balloon procedure is done. This same group
of investigators did a preliminary study giving the capsules
just 24 hours before the balloon angioplasty procedure. In
that study there was no difference in the recurrence of blockage
rate in the men getting the capsules and those who did not.
In the main study, the men started taking the capsules seven
days before treatment with the balloon. That would give enough
time for the omega-3 fatty acids to be incorporated in the
walls of the cells of the involved arteries.
While there are a number of unanswered questions about how
it works, and when is the best time to give omega-3 fatty
acids, this study suggests that these highly polyunsaturated
fatty acids may be quite important in preventing the high
rate of recurrent blockage of coronary arteries after the
balloon procedure. Once again, it suggests an important role
of fish oil in preventing coronary artery blockage. That adds
weight to the importance of including some of these fish in
your diet.
Keep in mind that other studies have shown that you can help
prevent blockage of the graft used in coronary bypass operations
by reducing your heart attack risk factors. That includes
not smoking cigarettes, lowering your total cholesterol level,
increasing your HDLcholesterol level and keeping your blood
pressure down. These measures are also important after having
the balloon procedure to open blocked coronary arteries.
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