A major new federal trial presented at the American Heart Association’s Scientific Sessions (November 16 to 18, 2019) in Philadelphia suggested that many patients living with severely clogged arteries may be just as well off relying on medication and lifestyle interventions, such as diet and exercise. “Even 10 years ago, studies started to show that the medications had gotten so good at preventing heart attack and death from heart disease that stents and surgery might not add much,” says Harmony Reynolds, MD, study investigator and associate professor of medicine at NYU Langone Health in New York City. “We wanted to see if we needed these invasive procedures for the stable patients at all.”
Equal Outcomes With or Without Surgery or Stenting
Dr. Reynolds and collaborators followed 5,179 participants with moderate to severe stable heart disease and found that a bypass or surgical repair of a blocked blood vessel did not reduce the risk of heart attack, death, heart-related hospitalizations, or resuscitation after cardiac arrest compared with an initial conservative approach using optimal medical therapy for patients with stable ischemic heart disease (SIHD). With SIHD, patients have an inadequate supply of blood to the heart due to deposits of plaque in the arteries but they are in stable condition. The $100 million study, called ISCHEMIA, followed participants with SIHD at 320 sites in 37 countries for between 1.5 and 7 years (an average of 3.3 years). They were divided into two groups — one receiving medical treatment alone and one receiving invasive procedures. Compared with those who only had medical therapy, individuals who had invasive treatment experienced about a 2 percent higher rate of cardiac events during the first year. In the second year, no differences were noted, and by the fourth year, event rates were 2 percent lower in individuals who underwent invasive procedures compared with those who only received the medical treatment and lifestyle advice. When looking at the overall difference between the two strategies, however, investigators found the outcomes to be equal. The results suggest that even if patients had 80 percent blockage, they would be okay with just drug treatment and lifestyle interventions as long as they are stable, according to Reynolds. She stresses that lifestyle changes — eating healthy, exercising, making sure not to smoke, and maintaining a healthy weight — are an essential part of the treatment. “We know that invasive procedures have an upfront risk and the question is does that get offset by a lower risk later on,” she says. “Overall, there was no evidence of a difference. Patients may want to accept an upfront risk [with a medical procedure] and down the line there may be a benefit, but most people felt better with the medicines only anyway. So I think the message to patients is: There is no rush to have a medical intervention.”
Recognizing Stable and Unstable Angina
Patients with stable angina (chest pain and discomfort) can have pain that occurs during activities but then it goes away with rest. Pain that is more severe and lasts longer than 10 minutes is unstable angina. This can be a warning sign of a heart attack. If there’s damage to the heart due to heart attack, then surgery or a stenting procedure is necessary. “It’s perfectly acceptable to have some chest discomfort if, say, you’re walking or under emotional stress as long as when you rest or relax it goes away in a few minutes,” says Reynolds. “But if chest pain comes on usually without a warning, when doing nothing, and doesn’t go away after 10 minutes, then the American Heart Association says get to a hospital to check for heart damage.” Sarah Samaan, MD, a cardiologist with Baylor Scott & White Legacy Heart Center in Plano, Texas, who was not involved in the study, underscores that the results do not change how heart attacks are managed. “In practical terms, it may be appropriate to try medical therapy for stable symptoms first, followed by invasive treatment for those who fail medical therapy, whether that is due to ongoing symptoms or to intolerance to medications,” says Dr. Samaan.
A Potential Game Changer for Treatment
The American College of Cardiology estimates that nine million Americans have stable angina chest pain symptoms. According to results from the Framingham Heart Study, published in December 2015 in the International Journal of Epidemiology, 500,000 new cases of stable angina occur each year. Based on the findings so far, thousands of heart patients may be advised to avoid elective surgery and still have the same outcomes. Reynolds and her team intend to follow patients over a longer period of time to see if these results are maintained. “I think this will save a lot of people from getting procedures that they do not need,” says Reynolds. “This practice should be changing.”
