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A study casts doubt on the need for many cardiac procedures



PHILADELPHIA (AP) – People with severe but stable heart disease from clogged arteries may have less chest pain if given a procedure to improve blood flow rather than simply giving the drug a chance to help, but this will not reduce their risk of heart attack or death over the next few years, a large, federally funded study

revealed that the results challenge medical dogma and call into question some of the most common cardiac care practices. They are the strongest evidence that tens of thousands of expensive stent procedures and bypass every year are unnecessary or premature for people with stable illness.

This is a different situation from a heart attack when an immediate recovery procedure is needed.

For urgent cases, the study shows "no need to rush" in invasive tests and procedures, said Dr. Judith Hohman of New York University.

There may even be harm: To the surprise of physicians, study participants who had a procedure were more likely to suffer a heart problem or die the following year than those treated with medication alone.

Hohmann led the study and delivered the results Saturday at a conference of the American Heart Association in Philadelphia.

"This study clearly contradicts the usual wisdom of the last 30, 40 years," and may lead to less testing and invasive treatment for such patients in the future, said Dr. Glenn Levine, a cardiologist at Baylor College of Medicine ", With no role in research. Some doctors can still argue with the study, but it was very well done "and I think the results are extremely plausible," he said.

About 1

7 million Americans have blocked arteries that obstruct the blood supply to the heart, which can cause periodic chest pain. Cheap and generic aspirin, cholesterol-lowering drugs and blood pressure medicines are known to reduce the risk of heart attack for these people, but many doctors also recommend a procedure to improve blood flow.

This is either a bypass – an open heart bypass surgery – or angioplasty, in which doctors push a tube through an artery to a blockage, inflate a small balloon and place a stent or mesh skeleton to support the artery open.

12 years ago, a large study found that angioplasty was no better than drugs for the prevention of heart attacks and death in non-emergency cardiac patients, but many doctors expressed their results and disagreed with the methods.

So the federal government spends $ 100 million on a new study that is twice as large, spanning 37 countries, and includes people with more serious illness – the group most likely to benefit from stents or bypass.

All 5179 participants had stress tests, usually done on a treadmill, with the blood supply being suppressed. All were given lifestyle tips and medicines that improve heart health. Half of them also received CT scans to rule out dangerous blockages, and then continued with their medication.

Others were treated as many people now do with abnormal stress tests: They were taken to cardiac catheterization laboratories for angiograms. The procedure involves placing a test tube in the main artery and using special dyes to depict the blood vessels of the heart. The blockages were treated immediately, with angioplasty in three quarters of the cases and bypass in the others.

Doctors then track how many of each group have suffered a heart attack, cardiac death, cardiac arrest, or hospitalization for worsening chest pain. or heart failure.

After one year, 7% in the invasive treatment group had one of these events versus 5% of those on medication. At four years the trend reversed – 13% of the treatment group and 15% of the medication group had a problem. Over the entire study period, the rates were similar regardless of treatment.

If stents and bypasses do not carry an individual risk, "I think the results would prove to be of common benefit to them," said another study leader, Dr. David Maron of Stanford University. "But that's not what we found. We found early harm and later benefit, and they canceled each other out. ”

Why can medicines be just as effective in reducing the risks?

Bypasses and stents fix only a small area. The medicines affect all arteries, including other spots that may become clogged, experts said.

Drugs have also improved significantly in recent years.

Although the procedure proved to be better for reducing chest pain. Of those who had pain every day or week when they entered the study, half of the stent or bypass group were without it within one year versus 20% of those who took medication alone. The placebo effect can swing these results – people who know they have had a procedure tend to credit it with any improvement they perceive in symptoms.

Dr. Alisa Jacobs, a cardiologist at Boston University who led a panel of treatment guidelines several years ago, said any placebo effect fades with time and people with a lot of breast pain that aren't drug-free may still want a procedure .

intuitively that if you remove the blockage, you will do better, you will feel better, "but the decision depends on the patient and the doctor, she said.

Bottom line: No harm in trying drugs first, especially

When told they have a stent-fixing problem, "most patients in my experience will choose to undergo this procedure" improved immediately, said Dr. Jay Geary, a cardiologist at the University of Pennsylvania with no role in the study. [19659002] Merian Birnes-Alvarado is not among them.The 66-year-old woman in New York said she joined the study six years ago after having trouble walking, which "scared me to death" but that's how it came about and the idea of ​​a cardiac procedure.

She was relieved when he was assigned to the medication group, and her doctor changed her blood pressure medication, added cholesterol and aspirin, and adjusted her diet. Now her risk factors are better and she can walk again without difficulty.

"I believe I had the best care I can get," and I avoid surgery, she said.

Marilyn Markione can be followed on Twitter at http://twitter.com/MMarchioneAP

The Associate Press Health and Science Division is supported by the Howard Hughes Institute of Science Education . AP is solely responsible for all content.


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