New procedure ensures accuracy, practicality in handling heart attacks

Dr. Howard Herrmann goes over Joseph Wills' echocardiogram. Willis has had several heart procedures. ( RON TARVER / Staff Photographer )
Dr. Howard Herrmann goes over Joseph Wills' echocardiogram. Willis has had several heart procedures. ( RON TARVER / Staff Photographer ) (RON TARVER / Staff Photographer)
Posted: February 22, 2013

TWO MEN - one 52, one 72 - entered Doylestown Hospital days apart this month, each suffering from chest pains.

The younger man was found to have minor blockages in an artery and was told by Dr. Joseph McGarvey Jr., an interventional cardiologist, that he would need only medication and lifestyle changes.

The older man had more serious blockages, and McGarvey swiftly scheduled him for bypass surgery.

Both likely would have been treated differently just a few years ago.

The younger man might have received an unnecessary stent, a tiny mesh tube to prop a vessel open.

The older man might have missed a surgery that turned out to be necessary. "He did beautifully," McGarvey said.

What's new is that McGarvey is being guided by a diagnostic procedure that helps cardiologists get a clearer sense of how serious arterial blockages are and how aggressively they should be treated.

The procedure, fractional flow reserve (FFR), dates to the mid-1990s, but has become more widely used in the past five years, not just because studies have found it effective, but because research is disputing the need to give stents to all patients.

For the procedure, the physician inserts a catheter through the groin or wrist artery, injects X-ray dye into the coronary arteries and makes a film of the blood- flow pattern, showing the location and size of any blockages.

In past years, a physician might have relied more on this imaging procedure, called angiography, to decide what to give a "stable" patient. (Patients suffering heart attacks immediately get stents to stabilize them.)

But with FFR, physicians can determine how much the blockage is truly impeding blood flow. "It determines the importance of the blockage," McGarvey said, "not [just] how blocked the artery is."

A wire with a small sensor is guided up the catheterization tube to the blocked areas. Using a drug to maximize blood flow, the physician can measure the pressure on either side of the blockage and see what effect it is having on flow.

The combined procedure, done with a local anesthetic, can take as little as 30 minutes, and enable the patient to be sent home that day.

Although stenting a stable patient is not considered high-risk, no surgery is risk-free, and cardiologists want to avoid it when possible. And, of course, there are cost savings to consider.

"If somebody doesn't need a stent, even a small risk is unacceptable," said Dr. Howard Herrmann, director of interventional cardiology at the Hospital of the University of Pennsylvania.

One of his patients, Joseph Wills, 63, agrees.

A retired chief financial officer for the Philadelphia Redevelopment Authority, Wills was admitted to HUP on a Saturday morning in early December with what Herrmann called "a fairly severe heart attack."

Herrmann stented the most severe blockage and stopped the attack. But he noticed that two other arteries were partly blocked and told Wills that he might need stents in each. He performed the FFR procedure the next Monday and told the patient that only one stent would be needed. The other blockage wasn't serious enough.

"I was thrilled," Wills said. "I didn't want any more [stents]. I look it at this way: It saves a lot of money, and I'd rather have a God-given artery than a man-made object."

Previously, Herrmann said, "the tendency had been to act" just on images from the angiography.

Dr. Timothy Shapiro, director of the Cardiac Catheterization Laboratory at Lankenau Medical Center, said that he has done the FFR procedure "hundreds of times" when the angiography doesn't give a clear answer and that more than half the time he ends up not stenting the patient.

"When it comes to stenting, there's no such thing as an easy case," added Dr. Brian O'Murchu, associate director of the Cardiac Catheterization Laboratory at Temple University Hospital.

FFR has become more common because of studies questioning the value of stents for stable patients, who may show symptoms such as chest or arm pain and shortness of breath, but are not having a heart attack. In the emergency room, stents save lives.

A 2007 trial indicated that stents were no better at prolonging life or preventing heart attacks than noninvasive treatment, such as medication and lifestyle changes.

Two years later, another trial indicated that physicians guided by FFR used about one-third fewer stents on average and that the results after one year were at least as good in terms of heart attacks and the need for more surgical intervention.

Stented patients also need an anti-clotting drug such as Plavix for several months, which can complicate care if they need more surgery.

And there's the cost. AARP estimates that Medicare alone paid some $3.5 billion to stent patients in 2009.

But mostly, Shapiro said, "it's better not to have a metal object inside you all your life unless you need it."


Contact Paul Jablow at pjablow@comcast.net.

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