New Orleans – People terrified by crippling chest pains want their doctors to do something fast to make them feel better and cut the chances they’ll have a heart attack or die.
For years, doctors have done artery-opening angioplasties for these reasons.
Now, stunning results of a landmark study have proved them wrong.
Researchers found that angioplasty did not save lives or prevent heart attacks in nonemergency heart patients.
An even bigger surprise: Angioplasty gave only slight and temporary relief from chest pain, the main reason it is done.
“By five years, there was really no significant difference” in symptoms, said Dr. William Boden of Buffalo General Hospital in New York. “Few would have expected such results.”
He led the study and gave results Monday at a meeting of the American College of Cardiology. They also were published online by the New England Journal of Medicine and will be in the April 12 issue.
Angioplasty remains the top treatment for people having a heart attack or hospitalized with worsening symptoms. But most angioplasties are done on a nonemergency basis, to relieve chest pain caused by clogged arteries crimping the heart’s blood supply.
Those patients now should try drugs first, experts say. If that does not help, they can consider angioplasty or bypass surgery, which, unlike angioplasty, does save lives, prevents heart attacks and gives lasting pain relief.
In the study, one-third of the people treated with drugs ultimately needed angioplasty or a bypass.
“You are not putting yourself at risk of death or heart attack if you defer,” and considering the safety worries about heart stents used to keep arteries open after angioplasty, it may be wise to wait, said Dr. Steven Nissen, a Cleveland Clinic heart specialist and president of the College of Cardiology.
One blockage at a time
Why did angioplasty not help more? It fixes only one blockage at a time, whereas drugs affect all the arteries, experts said. Also, the clogs treated with angioplasty are not the really dangerous kind.
“Even though it goes against intuition, the blockages that are severe that cause chest pain are less likely to be the source of a heart attack than segments in the artery that are not severely blocked,” said Dr. David Maron, a Vanderbilt University cardiologist who helped lead the study.
Drugs are better today than they used to be, and they do a surprisingly good job, said Dr. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute.
“It may not be as bad as we thought” to leave the artery alone, she said.
About 1.2 million angioplasties are done in the United States each year. Through a blood vessel in the groin, doctors snake a tube to a blocked heart artery. A tiny balloon is inflated to flatten the clog, and a mesh scaffold stent is usually put in place.
Some stents risky
The procedure already has lost some popularity because of emerging evidence that popular drug-coated stents can raise the risk of blood clots months later. The new study shifts the argument from which type of stent to use to whether to do the procedure at all.
It involved 2,287 patients throughout the U.S. and Canada who had substantial blockages, typically in two arteries but were medically stable. “We deliberately chose to enroll a sicker, more symptomatic group” to give angioplasty a good chance to prove itself, Boden said.
The study was funded by the U.S. Department of Veterans Affairs, the Medical Research Council of Canada and a host of drug companies. Stent-makers refused to help pay for the research, said scientists who led the study.
The study renewed a heated animosity between doctors who perform angioplasty and other heart specialists.
Dr. Spencer King of Piedmont Hospital in Atlanta, a leading cardiologist who does many angioplasties, said he was disappointed in the study results.
Disparate costs
An angioplasty costs roughly $40,000. The drugs used in the study are almost all available in generic form.
Maron said people should give the drugs a chance.
“Often I think that patients are under the impression that unless they have that procedure done, they’re not getting the best of care and are at increased risk of having a heart attack and die,” he said.
Dr. Raymond Gibbons, a Mayo Clinic cardiologist and American Heart Association president, agreed: “This trial shows convincingly that that assumption is incorrect.”
