• Posted November 7, 2022

Is Surgery Always Necessary for Folks With Chronic Angina?

Folks suffering chest pain from clogged arteries appear to have some true flexibility in choosing the medical care that's right for them, researchers report.

That's because their overall risk of death is about the same whether they choose aggressive surgical treatment or a more conservative approach focused on medication and lifestyle changes, according to seven-year clinical trial results.

These findings echo four-year results from the same trial, which is focused on people who have angina but no other serious heart-related complications, said lead researcher Dr. Judith Hochman, director of the Cardiovascular Clinical Research Center at the NYU Grossman School of Medicine in New York City.

"We can say with a little greater confidence that at seven years, there's no difference in survival between the two groups," she said. "Those patients, who are the vast majority of patients with chronic coronary disease, need to discuss with their doctor which is the best strategy for them."

Angina affects about 4% of Americans, or 11 million people, the American Heart Association (AHA) estimates.

The ISCHEMIA trial included people with moderately to severely clogged arteries who still had a healthy heart muscle, stable angina and no other recent heart-related illness. These results shouldn't be applied to patients with more complex heart conditions, Hochman said.

Nearly 5,200 qualifying patients in the trial were randomly assigned to one of two groups.

Patients assigned aggressive treatment typically underwent angioplasty or open-heart surgery based on their condition, Hochman said. Patients in the conservative treatment group were prescribed heart medications and asked to adopt healthy lifestyle changes.

After seven years of follow-up, patients in the conservative treatment group did have a greater rate of heart-related death, 8.6%, compared with 6.4% in the aggressive treatment group.

But the aggressive treatment group had a higher rate of non-heart-related death, 5.5%, compared with 4.4%.

"We really can't explain why non-cardiovascular deaths were increased in the invasive strategy," Hochman said. "But the two just cancel each other out, and all-cause death is the same for the invasive versus the conservative strategy over time. After seven years, the rates are the same."

Based on this, patients with simple angina should feel empowered to choose the treatment path that's right for them, Hochman said.

"If a patient with mild angina controlled by medical therapy wants these narrowings [of arteries] 'fixed,' which some patients do, it's very reasonable to go ahead and to that because they're not going to be harmed. They're not going to cut their life shorter based on that strategy," Hochman said.

"The same is true for a conservative strategy," she added. "There are many patients that just don't want invasive procedures. They don't want stents placed in them. They don't want open-heart surgery. It's very reasonable to say, 'Well, we know that after seven years if you take your medicines and make lifestyle changes, you're going to live just as long as the patients initially assigned to that invasive strategy.'"

They would not be selecting one strategy over the other based on survival.

"They'd be selecting it based on quality of life and their preference for management," Hochman said.

The clinical trial is set to go on for another three years, and will eventually provide a 10-year picture of differences between the two groups.

Some doctors are waiting for that full, decade-long analysis to see if a difference in survival eventually does emerge, said Dr. B. Hadley Wilson, vice president of the American College of Cardiology.

Wilson noted that heart-related deaths appeared to be steadily rising among those receiving conservative versus invasive treatment in the study.

"That really begets the reason for wanting to extend it, so we see if these curves would continue to separate. In other words, is there a difference between conservative management and invasive management, maybe not at five years but at 10 years?" said Wilson, executive vice chair of the Sanger Heart & Vascular Institute at Atrium Health in Charlotte, N.C.

The clinical trial results appear in the journal Circulation, and also were presented Sunday at the American Heart Association's annual meeting, in Chicago.

More information

The Cleveland Clinic has more about angina.

SOURCES: Judith Hochman, MD, director, Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York City; B. Hadley Wilson, MD, executive vice chair, Sanger Heart & Vascular Institute at Atrium Health, Charlotte, N.C.; Circulation, Nov. 6, 2022