'Stents vs. Drugs' Debate: Shared Decision-Making for Best Outcomes

Recentheadlines across the nation have referred to a major new study that comparedprocedures to unclog blocked arteries using stents to a medication-onlyapproach. “Stents vs. drugs” is a new phrase being bandied about.

The study found that people with stable heart disease, often without chest pain, had the same rate of major health events, such as heart attacks and hospitalizations from heart failure, after stent procedures as patients who received only medications, such as aspirin or statins, along with advice on lifestyle changes.

However, theU.S.-funded, international study also found that patients with symptoms ofangina — the chest pain caused by restricted blood flow to heart muscle — hadbetter symptom relief and quality of life that persisted for four years as aresult of stent procedures.

PercutaneousCoronary Intervention (PCI), formerly known as angioplasty with stent, uses acatheter (a thin flexible tube) to place the stent, a tiny tube made of eithermetal or plastic, to open up blood vessels in the heart that have been narrowedby plaque buildup, a condition known as atherosclerosis. The study found thatPCI is still beneficial for reducing angina in stable heartdisease patients.

What is the main takeaway from this major study for heart disease patients?

A more extensive “shared decision-making” between patients and their multidisciplinary medical teams should take place before treatment is applied, whether it involves PCI or solely medication therapy, says Marcus St. John, M.D., an interventional cardiologist and medical director of the Cardiac Catheterization Lab at Miami Cardiac & Vascular Institute.

“If youhave options, then we need to discuss them with the patient, so-called shareddecision-making,” explains. Dr. St. John. “There’s the conservativeapproach, which may involve taking more medicines and making lifestyle changesincluding a healthier diet and an exercise program, but there still may be aneed for a PCI in the future. The invasive approach does have some upfrontrisks because there are some possible complications from having a PCI. But PCIis good mostly for reducing angina and it can do that better than medication insome patients.”

The studyrandomly assigned 5,179 patients at 320 sites in 37 countries to receive one ofthe two treatment strategies. That makes it more than twice as large as anyprevious study of its kind. The study was led by researchers at NYU GrossmanSchool of Medicine and Stanford University. The data management and statisticswas handled by the Duke Clinical Research Institute (DCRI).

“It’simportant to note that the study did not apply to patients who had recently hador were having a heart attack, and it did not include very symptomatic patientswith chest pain at rest or during minimal activity,” points out Dr. St.John.

The studywas funded by the National Heart, Lung, and Blood Institute and it goes by theshort title of ISCHEMIA, which stands for International Study of ComparativeHealth Effectiveness with Medical and Invasive Approaches.

ISCHEMIAinvolved patients with stable ischemic heart disease (SIHD), which occurs whennot enough oxygen-rich blood is supplied to heart muscle. Most patients in thestudy had moderate or severe ischemia caused by atherosclerosis, cholesteroldeposits that narrow arteries. Ischemic heart disease affects 17.6 millionAmericans, resulting in about 450,000 deaths annually.

Patientsshould not feel “pushed into one position or another” — the invasiveapproach vs. medication only, says Dr. St. John.

“Thisis a reasonable study that says you can do quite well with an invasive approachand you are likely to be on fewer anti-angina medicines,” he adds.“But if you prefer not to undergo the procedure, we’re not increasing yourrisk of death. Having these options is important.”

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