The Atlanta Journal-Constitution
Stents, bypass surgery no more effective than drugs for many
Study examines rush to use invasive heart procedures.
Some of the most common invasive heart procedures in America are no better at preventing heart attacks and death in patients with stable heart disease than pills and lifestyle improvements alone, according to a massive federally funded study designed to resolve a long-standing controversy in cardiology.
Researchers found that invasive procedures to unclog blocked arteries — in most cases, the insertion of a stent, a tiny mesh tube that props open a blood vessel after artery-clearing angioplasty — were measurably better than pills at reducing patients’ chest pain during exercise. But the study, called ISCHEMIA, found no difference in a constellation of major heart-disease outcomes, including cardiac death, heart attacks, heart-related hospitalizations and resuscitation after cardiac arrest.
Overall, the keenly anticipated ISCHEMIA study results suggest that invasive procedures — stents and bypass surgery — should be used more sparingly in patients with stable heart disease and the decision to use them should be less rushed, experts said.
The $100 million trial, presented Saturday at the annual meeting of the American Heart Association ahead of publication in a peer-reviewed journal, is the latest entry into a long and contentious argument over how to treat artery blockages, one that has pitted powerful factions of American heart specialists against each other. It echoes a similar study 12 years ago that was heavily disputed by interventional cardiologists, the doctors performing the invasive procedures.
“This is a milestone study that people will talk about and write about for years to come,” said Elliott Antman, a cardiologist at Brigham and Women’s Hospital who was not involved in the study and praised it for the wealth of information gathered and the rigor and sophistication of the analyses.
“The ISCHEMIA trial shows that an early invasive approach does not protect patients against death or the overall chance of a heart attack, but does effectively relieve chest pain — the more chest pain a patient has, the more likely they are to benefit,” Antman said.
The ability to implant stents using a catheter inserted through blood vessels in the arm or groin has transformed cardiology over the past three decades. Stents have been clearly demonstrated to save lives in people who are suffering from a heart attack.
But as heart medicines such as statins have improved, there has been active debate about whether stents and other invasive procedures are more effective for people who aren’t in the throes of a heart attack, but have stable heart disease — generally defined as having clogged arteries, sometimes accompanied by chest pain when they exert themselves.
“If you go to major medical centers that do these procedures, you really talk to anyone, and they say after a very abnormal stress test there is a rush to schedule a cardiac catheterization because people have been afraid they’re at imminent risk of heart attack or sudden death,” said Judith Hochman, senior associate dean for clinical sciences at New York University Grossman School of Medicine and a leader of the trial. The new results show there’s “absolutely no risk in trying medicines, and seeing if the patient gets better — maybe they’ll become angina-free, and if not then they have to make a decision, do they want to take medications and have angina some of the time” or have a more invasive procedure.