Several controversial findings presented in the course of the American College of Cardiology meeting last week has almost certainly left a lot of heart patients wondering which method of treatment is best for their particular cardiovascular disorder.
Specialists claim that the answer has never been simple, and what is effective for one heart patient might not work for another.
"I believe that we sometimes try and make things too simple, in the media and in the scientific community," explained Dr Stephen Siegel, a cardiologist at the New York University Medical Centre in New York City. "The objective is to translate that information from evidence-based medicine, to take care of every patient."
The new research overturned the long-held concept that surgical techniques such as angioplasty and stenting were much better than medication therapy at treating stable heart disease. The usefulness and safety of costly, drug-coated stents have been questioned by other research. And other experiments trumpeted the expanding benefits of statins, posing the question of who shouldn’t be taking these medication.
Medicines equal to angioplasty
Let’s look at the angioplasty-against-drug therapy debate. The research of nearly 2 300 individuals revealed no differences in death, nonfatal heart attacks, strokes or hospitalization between persons with "stable" heart disease treated with medicines alone against those who received medications plus angioplasty and stenting.
Whereas a lot of cardiologists welcomed these results, stent producers and some interventional cardiologists (physicians specializing in procedures such as angioplasty) explained that the research was biased in favor of medication therapy. The experiment was supervised by American and Canadian health agencies, however did receive financial support from the pharmaceutical industry.
Nevertheless, Dr Raymond Gibbons, president of the American Heart Association, explained that the research simply "challenges an assumption that has frequently appeared in both patients and healthcare providers, which was that doing an angioplasty and stenting a blockage would decrease the likelihood of death and heart attack," he stated. "The experiment clearly proves that that is not the case."
Gibbons, who is also professor of medicine at the Mayo Clinic in Rochester, Minnesota, emphasized that the experiment had to pass muster not only with the ACC but with the tough peer-review board at the New England Journal of Medicine, which released the findings this week.
"Mayo, where I work, was a centre in this experiment," he added. "If we had had any concerns about the research’s design, we would not have taken part in it."
Does not apply to everybody
Gibbons pointed out that the results of the research only apply to individuals suffering chronic but stable heart disease. These persons may experience intermittent chest pain (angina) but have no history of heart attack.
"We have to remember that the research does not apply to acute heart attack [patients]," he explained. The research also can’t be applied to individuals suffering stable heart disease whose chest pain has not responded to medications, Gibbons added. Both of the groups are very proper candidates for invasive procedures such as angioplasty, he explained.
According to Siegel, in too many cases, individuals suffering stable heart disease are routinely sent off for an angiogram. And once healthcare providers observe an obstruction - any obstruction – they persuade the patients to undergo surgery in order to remove it.
"There’s clearly a gut reaction when you notice a closed artery - that it is much better to have it opened," explained Siegel, who is also clinical assistant professor at New York University School of Medicine. "However, the trouble with the whole concept of ‘opening everything’ is that it does nothing for the underlying disease."
Risks connected with surgery
Angioplasty and stents are both connected with some risk, he informed, and the latest research proves that, in many cases, it may be ideal to resist that the necessity to carry out surgery and check if medications can do the trick on their own.
Another specialist agreed. "If you are experiencing really horrible chest pain with exertion, it may be advisable to have a stent, however too frequently, they are being performed with just the promise of preventing a heart attack, and they do not do that," explained Dr Arthur Agatston, an associate professor of medicine at the University of Miami School of Medicine. He also said that he treats chronic heart disease patients with stents very seldom, preferring medicines and lifestyle alteration instead.
According to specialists, medications such as aspirin, statins, beta blockers and ACE inhibitors facilitate the inflammation and cholesterol build-up that leads to cardiovascular disease to star with.
"The key to remember here is that every patient requires medical therapy," Gibbons said, "due t the fact that angioplasty treats only the area of the artery with the serious blockage. If patients find a healthcare provider who does not seem to believe in optimal medical therapy, then they ought to look for another doctor."
Questions over drug-coated stents
Other research at the meeting emphasized the potential drawbacks of drug-coated stents, which can cost upwards of $2 000 each. Medicines inserted in the devices keep artery re-closure at bay, however the use of these devices has also been associated with the occasional development of large clots. Because of this reason, patients are recommended to take blood-thinners such as aspirin and clopidogrel (Plavix) for at least one year after stent placement.
Nevertheless, two studies revealed that some stented patients do not react to Plavix (raising their risk for clot), and around thirty per cent of patients fail to take the medicines as prescribed.
So, are drug-coated stents proper for everybody at great risk of experiencing heart attack or stroke? Of course not, the specialists said.
Due to the fact that the patients need to take blood-thinning aspirin and Plavix, "if the patient has elevated bleeding risks, then drug-eluting stents are not for them," Gibbons explained. "For individuals requiring non-cardiac operation within the next twelve months, drug-eluting stents do not constitute a good solution. Moreover, if patient’s resources are such that they are improbable to be able to afford clopidogrel for the next year, drug-eluting stents are not for them."
Otherwise, the benefit from a drug-coated stent is evaluated by healthcare providers on a case-by-case basis, Gibbons added. "The advantage frequently depends on the size of the blood vessel and individual patient characteristics," he said.
Good news concerning bad cholesterol
Eventually, there was more good news at the ACC meeting on the role of LDL ("bad") cholesterol-reducing statins. According to the findings of the research, the use of one medication of this kind, called Crestor, appeared to help keep plaque from settling in arteries. Another experiment discovered that the immediate use of Lipitor in the emergency room improved the long-term survival of patients after heart attack.
Statins usually bring about not many side effects, posing the question of whether everyone over a particular age might someday take them.
Like many heart specialists, Siegel is a big enthusiast of statins, which he called one of the "foundations" of existing therapy designed to reduce heart risks. Nevertheless, he explained, that he doesn’t recommend them across the board to patients.
"Let’s say you have an LDL cholesterol of 108 - a little bit over the 100 ‘desirable’ range but less than [the more hazardous] 130," he said. "Now, if you have a family history where your grandparents are alive at 98 years of age, and nobody’s ever had heart disease, I wouldn’t even think about prescribing it," Siegel explained. "On the other hand, though, if your father died at the age of 42 due to a heart attack, I don’t care what your cholesterol is, I would put you on a statin."
According to Siegel, the bottom line is that big clinical experiments are great, but each patient is unique.
"There’s not a huge group of patients’ sitting across from my desk, or on my exam table," he said. "It’s a person."
