Game Changer: Surgery For Blocked Arteries May Not Actually Be Necessary
By: Dr. Hesham A. Hassaballa
Tags: Surgery, Heart Attack, Health, Medicine, Research

Game Changer: Surgery For Blocked Arteries May Not Actually Be Necessary

Newly Released Research Upends Years of Clinical Practice

Photo by Piron Guillaume on Unsplash

Someone has an abnormal stress test, indicating a lack of blood flow to the parts of the heart under stress. Often times, the next step recommend by the Cardiologist is a cardiac catheterization, or angiogram. This is a picture of the arteries that supply blood to the heart. If there is a blockage, then something is done to fix it.

This coronary intervention, as it’s called in the business, is either a stent — a wire scaffolding that keeps the artery open — or sometimes, open heart surgery. It’s been accepted practice for a long time. As an ICU specialist, I frequently see such patients after their procedures in my ICU. Yet, was it really necessary? New research seems have to said, “Perhaps not.”

In brand new research presented at the annual meeting of the American Heart Association in Philadelphia, researchers said:

The trial showed that heart procedures added to taking medicines and making lifestyle changes did not reduce the overall rate of heart attack or death compared with medicines and lifestyle changes alone.

The same is true with those patients with chronic kidney disease.

The study was large (over 5000 patients were enrolled), randomized (the scientific gold standard), very well-conducted, and enrolled patients in several countries. The results were eagerly awaited, and they are truly a game changer. According to an article in The NY Times, “the nation could save more than $775 million a year by not giving stents to the 31,000 patients who get the devices even though they have no chest pain…”

Is a stent necessary after an abnormal stress test? New research says, “Perhaps not.”

Now, there were important caveats to these study results. These results do not apply to those patients having an actual heart attack. Evidence clearly shows that stents save lives in acute heart attacks. The results of this study only applies to those with stable symptoms. In fact, as researchers said, “The more chest pain to begin with, the more symptoms improved after getting a stent or bypass surgery.”

Now, were all those thousands of patients that received stents in the past mistreated? No, of course not. This study didn’t show that those randomized to the intervention arm suffered untoward harm.

At the same time, these results should give both doctors and patients pause when interpreting the results of an abnormal stress test. While the studies demonstrated that cardiac catheterization was exceedingly safe, they are still invasive procedures that are not without possible complications. And so, if medications alone, without a surgical procedure, can achieve the same results, this needs to be discussed thoroughly with your doctor.

What is most interesting to me is what the community of heart doctors will do in response to this new research. Indeed, as The NY Times article mentioned, “This is far from the first study to suggest that stents and bypass are overused. But previous results have not deterred doctors, who have called earlier research on the subject inconclusive and the design of the trials flawed.” I don’t think the same criticisms can be lodged against this trial.

These sorts of studies are always welcome. It is important that we physicians make sure that the treatments we recommend to our patients, as much as possible, or backed by solid scientific evidence. It is part of the constant process of learning, especially as new technology develops in Medicine. If some patients can be saved an invasive procedure, while achieving the same good outcome, this should make both doctors and patients happy.