Two new milestone studies, published in the New England Journal of Medicine (NEJM), seem to have settled the age-old controversy in cardiology. Both say that lifestyle modifications and medicine manage heart disease better than surgery and stents.
Original Article: Invasive or Conservative Strategy for Stable CAD
— NEJM (@NEJM) March 30, 2020
The study was funded by the National Institute of Health (NIH).
News: NIH-funded studies show stents and surgery no better than medication, lifestyle changes at reducing cardiac events https://t.co/gAiBl1N1M3
— NIH (@NIH) March 30, 2020
Cardiovascular diseases (CVD) are one of the major causes of death in the United States. In 2016 alone, it caused 840,768 deaths. According to a report by the American College of Cardiology, almost 6.2 million Americans suffered heart failure during 2013-2016.
The researchers wanted to study which strategy, either invasive and conservative, was better for a cardiac event.
Invasive heart surgery is also known as keyhole surgery that involves a small incision inside the heart through ribs, and includes angiography which is an X-ray of arteries in the heart. It also includes revascularization (bypass), a method to restore the organ that has suffered ischemia. Ischemic heart disease occurs when there is an inadequate supply of blood and oxygen to the heart muscle.
Conservative strategy includes an optimized medical therapy and a better lifestyle. This includes medicines to control blood pressure, cholesterol and ischemia, along with a better lifestyle such as diet and exercise.
To determine which strategy is superior, the researchers conducted two milestone studies. They collected a random sample that comprised of 5,179 patients with an average age of 64. The data was collected between August 2012 to January 2018 from 320 sites of 37 different countries. The patients had suffered some kind of heart problems in the past. The heart problems included heart attack, hospitalization for unstable angina, heart failure (HF), resuscitated cardiac arrest and cardiac death. Out of the total, 21% and 35% of the patients reported daily or weekly chest pain and no chest pain one month before the data collection, respectively. The team studied the impact of both of the techniques on the patients.
The investigators applied both strategies randomly to patients. The application of the strategies took five years of trials.
Conservative Treatment Group: The team found out that 21% of the patients ended up with stenting or bypass surgery that had conservative treatment and the rest of them continued their medication. The results suggest that 352 patients had gone through a cardiac event like heart attack and 144 deaths have been seen in this group.
Intervention Treatment Group: On the split side, 79% of the patients received revascularization and three-fourths of a whole ended up with stenting and other surgeries. In this group, a total number of 318 patients had experienced cardiac events and 145 deaths were recorded by the researchers.
By taking all the results into account, the researchers found that the death rate of both of the groups was almost the same. They also determined that the conservative treatment group and intervention treatment group had fewer cardiovascular problems during the first two years and the last two years of trials, respectively.
The co-author of the study, Judith Hochman, M.D., senior associate dean for Clinical Sciences NYU Grossman School of Medicine, says:
We have known and confirmed in this study that stent and surgical procedures have a risk of some heart damage. However, we saw that the heart damage related to a procedure was not as serious in terms of the risk of subsequent death compared to heart attacks that occurred spontaneously, unrelated to any procedure.
Replying to a question by Health Units on how much time it will take to determine which strategy is better to reduce the risks of ischemic heart disease, John Spertus, M.D., M.P.H., director of health outcomes research at Saint Luke’s Mid America Heart Institute in Kansas City, MO., and co-principal investigator for the ISCHEMIA quality of life analysis, says:
I would think that trying medications alone for three or so months seem quite reasonable. If there is improvement in angina symptoms, then continue with medicines alone. If there is still chest pain that bothers them, then offering angiography and revascularization is a great option.
The team did not find a shred of authentic evidence to prove that conservative and intensive strategy has played a role in the patients of cardiovascular diseases. So, long-term follow-ups of patients will be needed for better outcomes.