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Surgery May Not Be Beneficial for People With Stable Heart Disease
by Krisha McCoy, MS
Coronary artery disease occurs when the heart's arteries become narrowed, compromising blood flow to the heart. Percutaneous coronary interventions (PCI) are commonly used to treat heart disease. PCI typically include balloon angioplasty, which involves widening a narrowed artery with a small balloon. This procedure may be accompanied with the placement of a stent designed to keep the artery open. More advanced drug-eluted stents continuously release a medication to help prevent clotting.
There is some controversy surrounding the use of PCI in people with coronary artery disease. Guidelines from organizations including the American Heart Association recommend lifestyle interventions and medications as initial treatment of stable coronary heart disease, which is less likely to become complicated than unstable disease. Nonetheless, PCI procedures are often performed electively in people with stable coronary artery disease.
A new study in the April 12, 2007 New England Journal of Medicine compared lifestyle interventions and medications (known as optimal medical therapy) alone with optimal medical therapy plus PCI in treating stable coronary artery disease. The researchers found that while the addition of PCI helped relieve angina (chest pain), it did not reduce the risk of death or major cardiovascular events.
About the Study
This study included 2,287 people who had stable coronary artery disease. About half of the participants were assigned to receive optimal medical therapy alone (the medical-therapy group), and the other half were assigned to receive PCI plus optimal medical therapy (the PCI group). Medications included antiplatelet agents (eg, aspirin), statins (to lower cholesterol), angiotensin-converting enzyme (ACE) inhibitors (to treat high blood pressure), and beta-blockers (to lower blood pressure and prevent angina). Lifestyle interventions included recommendations to:
After an average follow-up period of 4.6 years, 211 participants in the PCI group and 202 in the medical-therapy group had died or had a nonfatal heart attack. There was no significant difference between the groups in risk of death, heart attack, stroke, or hospitalization for acute coronary syndromes (worrisome angina without heart attack). PCI, however, was more effective at reducing angina than optimal medical therapy alone.
This study was limited because most of the participants were men and white, so its findings may not apply to other groups of people. In addition, since drug-eluting stents were not approved until the final six months of the study, most participants did not receive these stents.
How Does This Affect You?
These findings support current clinical guidelines that recommend optimal medical therapy alone in the initial treatment of people with stable coronary artery disease. Keep in mind, however, that many people who are diagnosed with stable coronary artery disease will eventually need to undergo an invasive procedure. In fact, nearly 33% of the participants in the medical-therapy group in this study needed such a procedure during follow-up.
The decision of how to treat your heart disease is a highly individualized one, and depends on many factors. If you have stable coronary artery disease and are doing well on medical treatment, there is little evidence that an invasive procedure would provide additional benefit. However, be sure to alert your doctor if your symptoms change or worsen, since this may be an indication that medical treatment is no longer sufficient.
American Heart Association
National Heart, Lung, and Blood Institute
Boden WE, O-Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med . 2007;356:1503-1516.
Hochman JS, Steg PG. Does preventive PCI work? N Engl J Med . 2007;356:1572-1574.
Last reviewed May 2007 by Richard Glickman-Simon, MD