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Medication Protects Heart Patients As Well As Invasive Procedures

Findings from ISCHEMIA trial may mean fewer stents and bypass operations for those with stable disease

Medication and lifestyle changes appear just as effective as stent implants and bypass procedures at preventing major cardiac events among patients with severe but stable heart disease, a large new study shows.

The ISCHEMIA trial compared patients who underwent routine, invasive procedures (such as stenting or bypasses) with patients who received only medications (such as aspirin or statins) plus lifestyle advice. The invasive procedures did not reduce the rate of occurrence for a group of five cardiac events: cardiovascular death, heart attack, hospitalization for unstable angina, hospitalization for heart failure, or resuscitation after cardiac arrest. ISCHEMIA also found no overall difference between the two treatment strategies in the rates of cardiovascular death or heart attack considered separately.

However, for patients with angina, invasive treatments resulted in better symptom relief and quality of life that persisted for four years. Among those with daily or weekly angina at the start of the study, 50% of those treated invasively were angina-free after a year, compared to 20% of those treated with medications and lifestyle advice alone.

Both patient groups received "optimal medical therapy" (OMT), the term for medications and lifestyle advice, with one group undergoing invasive procedures soon after having an abnormal stress test and the other treated invasively only if symptoms worsened despite drug therapy or in the case of an emergency (heart attack). The study randomly assigned 5,179 patients at 320 sites in 37 countries to receive one of the two treatment strategies, making it more than twice as large as any previous study of its kind.

ISCHEMIA Study Chair Judith Hochman, MD, of NYU Langone Health, said the risk of heart attacks related to procedures may explain why the combined rate of cardiac events was higher over the first year among those who had an invasive procedure than those who received OMT alone (5.3% versus 3.4%, respectively). The event rate was roughly the same between the two approaches by year 2 (9% versus 9.5%) but slightly better among patients with invasive procedures at year 4 (13.3% versus 15.5%). Overall, the trend shifts over time showed no significant evidence of a difference in rates between strategies.

"Based on our results, we recommend that all patients take medications proven to reduce the risk of a heart attack, be physically active, eat a healthy diet, and quit smoking," says ISCHEMIA Co-Chair David Maron, MD, of Stanford University. "Patients without angina will not see an improvement, but those with angina of any severity will tend to have a greater, lasting improvement in quality of life if they have an invasive heart procedure.”

Source: NYU Langone Health, November 16, 2019

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