Most important, expert says, is to aggressively try to reduce risk factors
Treating people with non-acute heart problems should start with drug therapy, not invasive techniques such as angioplasty or implanting stents, because there is no difference between the two approaches in outcomes, a new study finds.
There has been an ongoing debate over whether initial treatment of people with non-acute heart problems should be with drugs or whether it would be better to open blocked heart arteries with a catheter — called percutaneous transluminal balloon coronary angioplasty — with or without a bare-metal or drug-coated stent, a wire mesh tube used to prop open an artery.
“In the short run, angioplasty procedures among stable patients can improve symptoms but are not lifesaving,” said Dr. David J. Moliterno, chief of cardiovascular medicine at the University of Kentucky’s Gill Heart Institute.
“To improve life span takes more than a few minutes in the catheterization laboratory,” he said. “Rather, a lifetime of change is usually needed.”
The report was published in the March 14 issue of The Lancet, in advance of an American College of Cardiology meeting in Orlando, Fla. Moliterno wrote an accompanying editorial in the journal.
For the study, a team led by Dr. Thomas A. Trikalinos, from the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center in Boston, identified 61 clinical studies that compared medical therapy, or drug treatment, with angioplasty and stents. The trials included a total of 25,388 people. The researchers documented deaths, heart attacks and cardiac bypass surgeries, and repeated procedures after initial treatment.
They found that angioplasty and either bare-metal or drug-coated stents did not result in fewer deaths or heart attacks compared with medical therapy.
“The reason for the similar outcome is likely that these hardest endpoints occur at a relatively low rate among stable cardiac patients when followed for a short period of time and are more affected by risk factor and lifestyle modifications,” Moliterno said.
People with stable coronary artery disease, he said, should not expect angioplasty, with or without use of a stent, to affect mortality or the occurrence of a heart attack.
“Rather, regardless of whether a patient requires angioplasty for symptoms, all patients should continue, as a primary treatment, to focus attention to aggressive risk factor modification,” Moliterno said. “In other words, it’s not just about the current severe blockages but about the underlying pathology causing the blockages.”
Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles, said he agrees that invasive procedures should be reserved for people with unstable cardiac problems.
“Percutaneous coronary interventions have been demonstrated to substantially improve clinical outcomes in patients with ST segment elevation, acute myocardial infarction and, in select groups of patients, with unstable angina and non-ST segment elevation acute myocardial infarction,” Fonarow said. “Percutaneous coronary intervention is evidence-based, guideline-recommended therapy for these indications.”
Though angioplasty might reduce symptoms in some people with stable coronary artery disease, he said, no individual study has demonstrated a comparative reduction in the number of heart attacks or deaths.
“This new meta-analysis demonstrates that balloon angioplasty, bare-metal stents and drug-eluting stents do not improve the clinical outcomes of death or myocardial infarction compared to medical therapy,” he said.
Most people with stable coronary artery disease “are better off with initial treatment with optimal medical therapy, reserving percutaneous coronary intervention for those patients with persistent symptoms despite optimal medical therapy,” Fonarow said.
Another report in the same issue of The Lancet found that, after two years of follow-up, bioabsorbable polymer drug-eluting stents, which are reabsorbed by the body, were safe and effective.
None of the 30 people who participated in the study died or needed further treatment of the stented artery during those two years, and there were no new blockages of the artery caused by the stent, the researchers found.
Biodegradable stents were developed to eliminate problems with metal stents, which can cause new blockages and can interfere with magnetic resonance imaging.
“All these findings need to be confirmed in larger studies, but this or similar devices could become of paramount importance for the restoration of vascular integrity in the treatment of flow-limiting plaque,” the authors concluded.