TORONTO (CP) - People with heart disease who are treated with a regime combining heart drugs and lifestyle changes did just as well as patients who had a common medical procedure known as angioplasty to unblock clogged arteries, a major new international study has found.
The surprising results, revealed at the American Cardiology Conference in New Orleans on Monday, are likely to fuel an ongoing debate between cardiologists who stress long-term approaches to treat the underlying heart disease and cardiologists who favour inserting small metal tubes called stents into arteries to fix blockages.
But over time, it will likely relegate angioplasty to the ranks of a procedure cardiologists resort to only if drugs and counselling to encourage lifestyle changes - weight loss, increased exercise, smoking cessation - don't achieve the desired effect, some experts said.
"This is an important study that will change the way we practise cardiology," said Dr. Beth Abramson, a Toronto cardiologist and spokesperson for the Heart and Stroke Foundation. (Abramson was not involved in the study.)
"This is a study that confirms that when you treat people well . . . they don't necessarily need a fancy intervention with newer technologies."
Patients will be better off for not undergoing procedures they don't need, said the lead Canadian researcher in the trial, which was conducted in 50 centres in the United States and Canada.
"All of us try to do the best we can for our patients, without putting them at risk," said Dr. Koon Teo, a cardiologist at Hamilton Health Sciences Centre who also teaches at McMaster University.
"Angioplasty is relatively safe but still there is a risk from it. And if patients don't have to go for angioplasty, that is good for them."
In 2003-04, the most recent year for which there are statistics, there were 167 angioplasties performed for every 100,000 Canadians over the age of 20, according to the Canadian Institute for Health Information.
The study was led by Dr. William Boden at Buffalo General Hospital in New York state, with funding from the U.S. Department of Veterans Affairs, the Canadian Institutes of Health Research and a variety of pharmaceutical companies.
The findings will be published in the New England Journal of Medicine next month.
Boden and colleagues started the study about 10 years ago, when a range of new and effective heart medications - including cholesterol-lowering statin drugs - were coming into the cardiovascular care picture.
They knew these drugs worked and wondered whether layering procedures like angioplasty - which involves threading a balloon into an artery to the site of a blockage and then inflating it - and stent insertions would result in even further improvements for their patients, Teo explained.
Their hypothesis was that the combined approach would be better. "But results of the . . . trial demonstrate that two treatments are not always better than one," Boden said in a statement.
A total of 2,287 patients with existing heart disease were randomly assigned to either have angioplasty or to receive what is called optimal medical therapy. That involved prescribing for them a range of important drugs to control blood pressure, lower cholesterol and prevent clotting, as well as urging them to exercise, eat a healthy diet and quit smoking. (All the patients in the angioplasty group also received the range of heart medications.)
After following the patients for an average of 4.6 years, the researchers found that there was no real difference between the two groups in terms of the rates of deaths caused by heart disease, heart attacks or strokes.
Both groups experienced a major reduction in the amount of angina - chest pain - they suffered, though the improvement was initially greater in the patients who had undergone angioplasty. By five years, however, angina rates were almost identical between the two groups.
Teo said the findings should help cardiologists feel confident a longer-term approach can be just as useful for stable heart patients as a quick fix. (The findings do not apply to patients suffering a heart attack.)
"There's always this concern that if we don't do something, something bad may happen," he said.
And Abramson said it should help get the same message across to patients who need to understand that heart disease can't be made to disappear with the help of a single procedure.
"Patients who are readers, who are often consumers, come into their physicians asking for that quick fix and asking for what they think may be the best, newest therapy," said Abramson, who practises at St. Michael's Hospital in Toronto.
"That newer intervention is not necessarily going to keep them alive any longer. And that's what this study shows - that long-term medical interventions, compliance with medications and making lifestyle changes are important."
Teo insisted there will still be a role for angioplasty and stent insertions, but as a fall-back, not a first-line, treatment option.
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