- Invasive procedures like stenting may not work better than medical and lifestyle changes for some types of heart disease.
- A new major study counteracts what many cardiologists have advised in the past.
- Experts say this may save patients millions of dollars.
Many people with blocked arteries in their heart may benefit as much from drug therapy and lifestyle changes alone as from bypass surgery or stenting procedures, a large study showed.
Dr. Satjit Bhusri, a cardiologist at Lenox Hill Hospital in New York City, who wasn’t involved in the study, says the results weren’t surprising.
“There has been data hinting at these findings from other trials,” he said. “What makes this study particularly important is that it statistically and scientifically proved what we all knew to be true.”
The new study is certain to add fuel to the ongoing debate among cardiologists about the best treatment for people with moderate to severe but stable ischemia.
The study was presented this month at the American Heart Association (AHA) annual meeting in Philadelphia.
Ischemia is a narrowing of the arteries. When it affects those that supply the heart, it can result in less blood and oxygen reaching the heart muscle.
This is known as ischemic heart disease. It often causes angina pectoris, or chest pain. In severe cases, ischemia can lead to a heart attack.
Stents are tiny mesh tubes that are inserted into an artery to keep it open after an artery-widening procedure called an angioplasty. Modern stents also release drugs inside the artery to decrease the chance that blockages will occur again.
Dr. Victoria Shin, a cardiologist with Torrance Memorial Medical Center in Torrance, California, who wasn’t involved in the study, says the “knee-jerk reflex” in some medical circles to treat stable ischemic heart disease with stenting has long been questioned.
But even after earlier studies finding that stents weren’t always the best call, some cardiologists were reluctant to change how they practiced.
However, the new study — given its size and that it took into account risk factors such as LDL (bad) cholesterol — may shift how cardiologists practice.
“This is a large, well-designed study that reminds us that just because it’s there, we don’t always need to fix it,” she said.
The 7-year new study, which enrolled more than 5,000 people, found that there wasn’t a large benefit for either putting in stents or performing bypass surgery invasive procedures.
Bypass surgery is another method of restoring blood flow to the heart. It involves rerouting blood flow around a blocked coronary artery using an artery or vein taken from another part of the body.
Overall, these procedures didn’t significantly reduce a person’s chances of having a heart attack, or dying from heart problems or any cause.
However, this group had a lower risk for heart attacks and other heart problems after 4 years, compared to the medical therapy group. The researchers say they’ll need to study this further.
Everyone in the study received medications and lifestyle advice, while half had a stenting or bypass procedure.
The study only included people who had a narrowing of their coronary arteries but with stable symptoms and no severe coronary artery disease.
Those with more severe heart disease — such as with unstable symptoms, a recent heart attack, or blockages in the left main coronary artery — were excluded.
This limits the findings.
“The study looked at a specific group of patients, so we can’t make statements about stents versus medications in all patients,” said Dr. Aidan Raney, a cardiologist at St. Jude Medical Center in Fullerton, California, who wasn’t involved in the study.
Bhusri says the discussion is really about how best to improve these patients’ quality of life and relieve symptoms like chest pain.
“If these [goals] are not accomplished with medicines and lifestyle modifications, a stent is then indicated,” he said. “A stent, however, will not change [these patients’] risk, or lack thereof, of having a heart attack or other major cardiac events in the future.”
This doesn’t mean there’s no place for invasive procedures in treating heart disease.
“Stents and bypass surgery are still very important for a lot of patients who were not included in this trial,” Raney said.
These procedures can also save lives.
“Certainly if someone is having a heart attack, there’s no question. Angioplasty and stent are recommended,” Shin said.
Shin thinks that for patients with stable symptoms, medical therapy and lifestyle changes should be the first option.
These methods work for many people and address the risk factors that led to the narrowing of the arteries in the first place.
“Interventions are a ‘quick fix,’ but they don’t solve the long-term problem: the milieu in which this disease process developed in the first place,” Shin said.
Additionally, researchers estimate that eliminating unneeded invasive procedures for this type of heart disease could save hundreds of millions of dollars in healthcare costs each year, reports Reuters.
Still, medical therapy isn’t for everyone.
“Certain patients can only tolerate certain levels of cardiac medicines, as these drugs predominantly work by lowering heart rate and blood pressure,” Bhusri said. “Alternatively, procedures are all invasive, and as such carry an inherent risk.”
Some patients who have a stenting procedure will also need to take anti-clotting drugs.
But if people opt for the noninvasive route, they may need to take several pills a day: cholesterol-lowering drugs such as statins, high blood pressure medications, aspirin, and sometimes a drug to slow heart rate.
In addition, lifestyle changes, like exercising more, eating healthier, and giving up smoking, can be challenging for many people to stick with.
“Patients should realize that they need to be compliant with recommended lifestyle modifications as well as taking medications as prescribed,” Shin said.
“If they have truly exhausted these resources, then an [invasive] intervention may be warranted for symptom relief,” she added.