Study casts doubt on need for many heart procedures
PHILADELPHIA — People with severe but stable heart disease from clogged arteries may have less chest pain if they get a procedure to improve blood flow rather than just giving medicines a chance to help, but it won’t cut their risk of having a heart attack or dying over the following few years, a big federally funded study found.
The results challenge medical dogma and call into question some of the most common practices in heart care. They are the strongest evidence yet that tens of thousands of costly stent procedures and bypass operations each year are unnecessary or premature for people with stable disease.
That’s a different situation than a heart attack, when a procedure is needed right away to restore blood flow.
For nonemergency cases, the study shows “there’s no need to rush“into invasive tests and procedures, said New York University’s Dr. Judith Hochman.
There might even be harm: To doctors’ surprise, study participants who had a procedure were more likely to suffer a heart problem or die over the next year than those treated with medicines alone.
Hochman coled the study and gave results Saturday at an American Heart Association conference in Philadelphia.
“This study clearly goes against what has been the common wisdom for the last 30, 40 years“and may lead to less testing and invasive treatment for such patients in the future, said Dr. Glenn Levine, a Baylor College of Medicine cardiologist with no role in the research. Some doctors still may quibble with the study, but it was very well done “and I think the results are extremely believable,“he said.
About 17 million Americans have clogged arteries that crimp the heart’s blood supply, which can cause periodic chest pain. Cheap and generic aspirin, cholesterollowering drugs and blood pressure medicines are known to cut the risk of a heart attack for these folks, but many doctors also recommend a procedure to improve blood flow.
That’s either a bypass — openheart surgery to detour around blockages — or angioplasty, in which doctors push a tube through an artery to the clog, inflate a tiny balloon and place a stent, or mesh scaffold, to prop the artery open.
Twelve years ago, a big study found that angioplasty was no better than medicines for preventing heart attacks and deaths in nonemergency heart patients, but many doctors balked at the results and quarreled with the methods.
So the federal government spent $100 million for the new study, which is twice as large, spanned 37 countries and included people with more severe disease — a group most likely to benefit from stents or a bypass.
All 5,179 participants had stress tests, usually done on a treadmill, that suggested blood flow was crimped. All were given lifestyle advice and medicines that improve heart health. Half also were given CT scans to rule out dangerous blockages, then continued on their medicines.
The others were treated as many people with abnormal stress tests are now: They were taken to cardiac catheterization labs for angiograms. The procedure involves placing a tube into a major artery and using special dyes to image the heart’s blood vessels. Blockages were treated right away, with angioplasty in threefourths of cases and a bypass in the rest.
Doctors then tracked how many in each group suffered a heart attack, heartrelated death, cardiac arrest or hospitalization for worsening chest pain or heart failure.
After one year, 7 percent in the invasively treated group had one of those events versus 5 percent of those on medicines alone. At four years, the trend reversed — 13 percent of the procedures group and 15 percent of the medicines group had suffered a problem. Averaged across the entire study period, the rates were similar regardless of treatment.