Coronary stent implants and bypass surgeries are no more effective than pills and lifestyle changes to treat patients with moderate or severe heart disease, though the efficacy of such invasive procedures is not doubted in emergency conditions, one of the world’s largest trials on heart patients has found.
The trial involved 19 Indian hospitals, including one from Bengaluru, and 300 others around the globe was designed to address a long-standing question in cardiology — what’s the preferred route to treat patients who are not in emergency but nevertheless have a serious heart problem?
Presented at the American Heart Association’s scientific sessions, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial involved 5,200 patients separated into two groups — one treated with pills, exercises and the other with stenting and surgeries. They were followed up for 3.5 years.
Researchers used five endpoints to check the efficacy of the two routes — death, heart attack, hospitalisation due to sudden and serious chest pain, hospitalisation due to heart failure and resuscitation after cardiac arrest.
Bengaluru’s Sri Jayadeva Institute of Cardiovascular Sciences and Research took part in the trial along with AIIMS, Delhi, and 17 other hospitals from Delhi, Chennai, Pune, Lucknow, Hyderabad, Ludhiana and Kerala.
The investigators reported that for patients with symptoms of angina (chest pain due to reduced blood flow to the heart), invasive treatments resulted in better symptom relief and quality of life that persisted for four years.
Among those with daily or weekly angina at the start of the study, 50% of those treated with surgery or angioplasty were angina-free after a year, compared to 20% of those treated with medications and lifestyle advice alone.
But the trial found no overall difference between the two treatment strategies at any of the endpoints such as death, heart attack or hospital stay for patients with chronic and stable angina.
Cardiologists caution that the ISCHEMIC trial results apply only to patients with chronic stable angina typically associated with brief episodes of pain, squeezing or tightness in the chest after exertion. The results do not apply to patients experiencing heart attacks or for those who don’t get relief after treatment with medicines. The emergency cases of stenting and bypass surgery are out of the purview of the trial.
Unfortunately in India, there are plenty of such chronic angina cases where doctors go for an invasive procedure. According to a study published in the Indian Heart Journal earlier this year, nearly 75,000 angioplasties (implanting a stent in the blood vessel) were carried out on patients with chronic and stable angina in 2017.
But as per the ISCHEMIA study, such patients could have been managed with medications and lifestyle changes.