International study backs preventive approach to heart disease

Matt Woodley

22/06/2020 3:45:44 PM

A global trial has found medicine and lifestyle changes can be as effective as invasive surgery in addressing stable coronary artery disease.

Monitoring heart
Nearly 5200 people with stable coronary disease and moderate-to-severe ischaemia were involved in the trial.

The ISCHEMIA Research Group – a contingent of more than 50 international medical researchers – analysed comparisons of invasive surgery and conservative surgery patients over more than three years to help form their findings.
The group’s Australian national lead researcher, Professor Joseph Selvanayagam from Flinders University, said the international effort is a ‘landmark study’ with an important message: Conservative early treatment of stable coronary disease is as effective as early coronary angiography and revascularisation for patients with and without advanced kidney disease.
‘This trial’s results show there is no need to rush patients with stable coronary disease, and moderate-to-severe myocardial ischaemia, to invasive coronary angiography,’ he said.
‘It is perfectly safe to treat these patients with cholesterol-lowering drugs, anti-platelet drugs and antianginal drugs, and then monitor their progress.
‘We did not find evidence that the initial invasive strategy reduced the risk of ischaemic cardiovascular events such as heart attacks or strokes, or death from any cause.’
GPs have consistently supported a preventive approach to medicine, but have been somewhat hamstrung by a lack of funding, with only 1.3% of the Federal health budget spent on preventing disease.
Nearly 5200 people with stable coronary disease and moderate-to-severe ischaemia were involved in the ISCHEMIA main trial, which took place in 320 centres across 37 countries.
The patients, 77% of whom were male and had a mean age of 64, were randomised to either a treat-to-target approach, which used guideline medications and resorted to angiography only if treatment failed, or the same approach plus angiography within 30 days and revascularisation if feasible.
‘In most cases, patients in the medical therapy arm did perfectly fine and did not need to have invasive angiography and stenting/bypass,’ Professor Selvanayagam said.
‘We can reserve stents or bypass options for patients who struggle with unacceptable side-effects from medications, or who have bad angina despite maximal medical therapies – although even here we have to make it clear to patients they are taking operative options for symptom relief.’
Heart attack or admission for unstable angina, heart failure or resuscitated cardiac arrest, or death from cardiovascular disease occurred in 353 patients in the conservative arm of the trial and 318 in the invasive arm – a difference which the researchers determined was not significant.
As such, the authors wrote that patients with ischaemic heart disease who fit the profile of those in ISCHEMIA and do not have unacceptable levels of angina, can be treated with an initial conservative strategy provided there is strict adherence to guideline-based medical therapy.
The number of deaths from any cause was 145 in the invasive arm of the trial versus 144 in the conservative arm over a median of 3.2 years of follow-up.
Cardiac computed tomography (CT) scans were used to screen and exclude patients with significant left main stem coronary disease from entering the trial.
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Dr Kylie Fardell   26/06/2020 8:25:47 PM

I thought previous trials had already established that lifestyle measures and medical therapy was at least as effective as PCI/stenting for stable angina. Am I missing something?