Stents can’t take the place of diet and exercise: What Indians should really take away from the ISCHEMIA trial
IHD occurs when cholesterol plaque builds up inside the walls of our arteries. This can later stop the blood flow to the heart and cause a heart attack.
Medical procedures such as inserting stents or bypass surgery aren't better (or worse) than medicines for reducing the chances of heart attack and other cardiac events in people living with “stable” ischemic heart disease, a landmark study, ISCHEMIA, has reported.
Ischemic heart disease (IHD) occurs when cholesterol plaque builds up inside the walls of our arteries. This can eventually stop the blood flow to the heart and lead to a heart attack.
The ISCHEMIA study focused specifically on people with stable ischemic disease.
“People who are not very symptomatic, who don’t have an acute illness, who don’t have a previous history of heart muscle damage, and who don’t have left main disease (that is, a blockage in the left main coronary artery that supplies blood to the left side of the heart) - essentially these are people who have ‘stable’ disease and in whom stenting is not likely to improve survival,” explained Dr Manish Bansal, senior consultant of preventive cardiology, Medanta - The Medicity hospital.
The ISCHEMIA trial followed 5,179 patients across the world—several Indian hospitals were a part of this study—and randomly assigned them to medical therapy alone or an interventional procedure along with medicine. Three-fourth of the patients in the intervention group received stents. Medical therapy consisted of lifestyle changes such as exercising, eating healthy and quitting smoking as well as cholesterol-lowering drugs such as statins.
The study focused on health outcomes such as cardiovascular death, myocardial infarction (heart attack), resuscitated cardiac arrest, and hospitalisation for unstable angina or heart failure. After 3.3 years 13.3% of those who got a stent or had bypass surgery had a cardiac event, compared with 15.5% people in the drugs-only group.
All-cause death was 6.4% in the group that had an interventional or surgical procedure as compared to 6.5% in the group that received medicines along with lifestyle changes.
"We have to remember, the study does not cover those who suffer from unstable angina, have had heart attacks, or have a blockage in the left main artery," said Dr (Col) Anil Dhall, a Gurgaon-based cardiologist. "For symptom relief and in emergency situations, surgical intervention is no doubt the correct response," he added.
The underlying problem
“In people who have stable heart disease, angioplasty with stenting is like a bandaid," Dr Bansal agreed. "Patients have to understand that the buildup of cholesterol plaque in the arteries (atherosclerosis) is a generalised process. It’s not like there is cholesterol blockage in just one part of your arteries and when we put a stent there, the problem is gone. Someone who has a 70% blockage in one section of their arteries will likely have plaque buildup in other areas too,” Dr Bansal said.
Stents and bypass surgery, in general, are better suited to alleviate symptoms of angina and emergencies rather than address the overall strain on the heart. Medical therapy, in addition to exercise and diet control, acts in a less specified, more holistic manner.
Are we seeing over-stenting in India?
The study suggests that not all the 4.5 lakh people who undergo cardiac surgery every year in India may actually need it. While ISCHEMIA is not the first study to suggest this, it is the most comprehensive.
“The findings of ISCHEMIA are staggering,” said Dr Dhall. “This is not to say that surgical interventions in the past have been excessive or unnecessary... It (the study) highlights critical aspects of healthcare delivery and patient-doctor relations. Treatments should be individualistic... based on the requirements and constraints of the patient. If these don’t bring an improvement in the patient’s quality of life, then intervention may be required, regardless of what ISCHEMIA says,” he said.
Live longer, live better
Dr Bansal said that there are of course cases where stenting is necessary. “Patients who have significant chest pain, those who have suffered damage to the heart muscle, as well as those who experience a sudden worsening of symptoms are likely to benefit from stenting. But even in their case, exercise and proper diet along with medication are absolutely essential to maintain quality of life as well as longevity.”
According to Dr Bansal, the key takeaway for Indians—we have one of the highest rates of heart disease globally—should be that medicines and lifestyle changes are ideal and stents are emergency fixes that don’t address the underlying problem.
“Unless we treat the disease process, the problem will return. (The disease process is basically more cholesterol buildup in the arteries as a result of poor lifestyle choices, lack of exercise and a lax attitude towards your medicines.) In patients who have significant angina or chest pain, stenting will reduce the symptoms. They will have a better quality of life, but they won't necessarily live longer. To live longer as well as better, we need to improve lifestyle and take appropriate medications,” Dr Bansal said.
The ISCHEMIA study was presented at the annual American Heart Association conference last week and has received international interest.
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