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Can Revascularization Outperform Drug For Ischemia?
Heart disease has been the number one killer globally. When a patient is diagnosed with heart disease, he or she should seek proper medical treatments by doctors. Treatments options usually include lifestyle changes, medications and medical procedures or surgery. Very often, the doctor will suggest to their patients whose conditions are not severe to have lifestyle changes. These include adopting a low-sodium and low-fat diet, exercising at least 30 minutes, 5 times a week, quitting smoking and limiting alcohol drinking. If this alone does not improve the condition, the doctor may prescribe medications, according to the patients’ condition, to control the heart disease. If both approaches still insufficient, the doctor will likely recommend appropriate procedures or surgery, such as angiography or even by-pass. Cardiologists have debated for more than decades the best way to deal with blockages in an artery, and when should procedures or surgery be performed. As procedures and surgery can be dangerous and costly, there is suggestion that medications, along with diet and exercise, should be used instead of procedures, especially because of advances in therapy. A recent finding revealed on November 16 at the 2019 American Heart Association Scientific Sessions in Philadelphia, Pennsylvania may actually provide answer to such debate.
The $100 million trial, ISCHEMIA (International
Study of Comparative Health Effectiveness With Medical and Invasive Approaches),
found that an early invasive approach does not protect patients against cardiac
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. The clinical trial, sponsored by the National Heart, Lung and Blood
Institute, was led by researchers at the Stanford School of Medicine and New
York University’s medical school.
Started enrolling participants in 2012, ISCHEMIA involved 5,179 participants at 320 sites in 37 countries. Participants selected were those who had moderate to severe ischemia, but who had not had a heart attack within the past 2 months. Ischemia, which is reduced blood flow, often causes symptoms of chest pain known as angina. About two-thirds of the participants suffered symptoms of chest pain. The participants were randomly divided into 2 groups. Both groups received medications and lifestyle advice, but only one group underwent invasive procedures. The study followed patients between 1˝ and 7 years, keeping tabs on any cardiac events. Results of the trial indicated that those who underwent an invasive procedure had roughly a 2 percent higher rate of heart events within the first year when compared with those on medical therapy alone. According to the investigators, this was attributed to the additional risks that come with having invasive procedures. By the second year, no difference was shown. By the 4th year, the rate of events was 2 percent lower in patients treated with heart procedures than in those on medication and lifestyle advice alone. The health events measured by the study included death from cardiovascular disease, heart attack, hospitalization for unstable angina, hospitalization for heart failure and resuscitation after cardiac arrest. As for patients who reported daily or weekly chest pain at the start of the study, 50 percent of those treated invasively were found to be angina-free after a year, compared with 20 percent of those treated with lifestyle and medication alone. Investigators concluded that this trend resulted in no significant overall difference between the 2 treatment strategies. They recommend that all patients should take medications proven to reduce risk of heart attack, be physically active, eat a healthy diet and quit smoking. But for those who have severe angina, having invasive heart procedure may help them get a greater and lasting improvement in quality of life. And they should talk with their doctors to decide whether to have revascularization.
The new findings would give patients and doctors a
solid ground to discuss the benefits and risks. For instance, an elderly patient
who has stable heart disease who is not very active but suffers some chest pain
may decide on drug therapy. On the other hand, a younger patient with more
frequent chest pain that impedes active daily life could choose an invasive
strategy. Date: December 19, 2019
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