Recently, Dr Oscar Rebelo, my loving nephew and an enlightened cardiologist, avid reader of medical literature, sent me the link to a novel study by the Stanford group. And, Oscar, seized with the evidence emanating from the Stanford researchers, triumphantly prefaced his forward thus, “Viva! This is something the good doctor from Margão, near the Holy Spirit Church, has been advocating for years…” Thanks Oscar. Since quite a few hit out at me during that time, I kind of feel vindicated now.
The large, international study led by Stanford and New York University found that invasive procedures are no better than medications and lifestyle advice at treating heart disease that’s “stable”.
Echoing these sentiments while writing for Herald many years ago, I had deprecated the fact that hundreds of thousands of individuals from around the world underwent unnecessary angioplasty and stent procedures to open clogged heart arteries, when landmark studies had shown that people with “stable” coronary artery disease who get blood-thinners and common medications to lower blood pressure and cholesterol levels were no more likely to die or to have a heart attack over the next five years than those who underwent angioplasty with stents.
What happens in coronary artery disease (CAD)? In people with CAD, plaque builds up in the arteries, making it harder for blood to get through, thereby depriving the heart muscle of oxygen. This can lead to chronic chest pain that worsens during exercise. What is chronic “stable” angina? It refers to precordial chest pain, usually precipitated by stress or exertion relieved rapidly by rest or nitrates. “Unstable” angina, on the other hand occurs at rest or in a crescendo manner.
What does an angioplasty achieve? A balloon at the end of a long tube is threaded through an artery in the arm or groin. Later, the doctor shimmies the probe up into the arteries of the heart, inflating the tiny balloon at the spot where the vessel has narrowed and deploys a stent.
The COURAGE study reported in 2007 that angioplasty and inserting stents (PCI or percutaneous coronary intervention) provided temporary relief from angina, but did not result in fewer deaths, heart attacks or cardiovascular events than medication and lifestyle changes.
Despite this information and the changes to professional medical society guidelines, a 2011 study reported no decline in the use of angioplasties. A number of media outlets covered the news, raising awareness among the public and questioning the continued reliance on procedures that were not shown to be effective. It would be expected that the use of angioplasty and stenting would decrease. But unfortunately that was not the case. Why? It could be a matter of money, medical analysts said!
The data from COURAGE came as a shock to many cardiologists, who saw symptomatic relief in patients after PCI. Having performed angioplasties in good faith, they thought they did a good job. Acting like “plumbers”, doctors were cocksure that PCI helping solve the “plumbing” problem of a blocked artery would do wonders. They chose to ignore that “inflammation”, for instance, is found nowadays to be a big contributing factor and surprisingly “most ruptures occurred in mild lesions”.
Misconceptions about the relationship between cardiovascular disease and narrowed arteries – with most patients erroneously expecting that a stent will reduce the chance of a future heart attack – may also have been at the root of the overuse of the procedure. As many as a million patients in the US were given stents (albeit unnecessarily) in the last decade costing upwards of $2.4 billion a year to the healthcare system.
The new international study led by Stanford and New York University reported that stents/bypass surgery show no benefit in heart disease mortality rates among “stable” patients.
The trial did show, however, that among patients with coronary artery disease who also had symptoms of angina — chest pain caused by restricted blood flow to the heart — treatment with invasive procedures, was more effective only at relieving symptoms and improving quality of life but did not improve mortality rates.
“For patients with severe but “stable” heart disease who don’t want to undergo invasive procedures, these results are very reassuring,” said David Maron, MD, director of preventive cardiology at the Stanford School of Medicine, and co-chair of the trial, called ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). “The results just don’t suggest they should undergo procedures in order to prevent cardiac events,” added Maron.
Coronary angioplasty admittedly has its downside. One concern is that too much scar tissue may grow in the treated area of the artery despite the availability of drug-eluting stents. This can cause it to become narrow or blocked again. Sometimes this happens within a matter of months.
Based on their results, Stanford researchers recommend that all patients take medications proven to reduce the risk of a heart attack, be physically active, eat a healthy diet and quit smoking.
“I think these results should change clinical practice. A lot of procedures are performed on people who have no symptoms. It’s hard to justify putting stents into patients who are ‘stable”, concludes Dr Maron.
As big corporates have made their appearance among us (frightening patients of dire consequences lest they fail to undergo angioplasty even for “stable” angina) it’s time to pause and ponder.
Alas, for many, it’s all about money, honey!
(Dr Francisco Colaço is a seniormost consulting physician)
