Do angioplasty and stents prolong life?

If you or a loved one has been diagnosed with coronary artery disease, you may be presented with the option to undergo a percutaneous coronary intervention (PCI) – an angioplasty and stenting procedure. Although highly technological interventions can sound appealing, these procedures have been found to have no advantage over medication and lifestyle changes for most people with stable heart disease.

Angioplasty is a procedure that is done to widen a coronary artery.  In the procedure, a thin tube is threaded into an artery narrowed by plaque, then a balloon is inflated to compress the blockage in an attempt to widen the vessel passageway and normalize blood flow.  A stent is then put into place after angioplasty to help prevent the blockage from re-forming.

A large clinical trial known as COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), whose findings were published in 2007 in the New England Journal of Medicine, concluded that angioplasty and stent procedures did not offer any survival advantage over medications alone. There were two groups of patients with stable coronary artery disease included in the study. One group was assigned to optimal medical therapy (OMT, also called guideline-directed medical therapy, GDMT), which consisted of modest lifestyle changes plus anti-platelet, blood pressure-lowering and cholesterol-lowering medications; the second group was assigned to PCI plus OMT.

After five years of follow-up, the group of patients receiving angioplasty or stenting did not have fewer heart attacks or cardiac deaths than the group who received OMT. These results were surprising to many in the medical community, but additional studies supported the conclusions. It was also found angioplasty and stenting did not provide any advantages over OMT for relief of angina symptoms.

Then in 2015, the COURAGE trial’s long-term survival data (approximately 12 years) was published, and still no difference in the number of deaths was found between the PCI group and the medical therapy group.

Why do angioplasty and stent procedures fail to prevent future heart attacks and prolong survival? The main reason is that the underlying disease process continues to progress if the patient does not make significant dietary improvements.  Atherosclerosis is a disease created by an unhealthy diet, and unless that is remedied further deterioration is inevitable.  Besides not addressing causation, these procedures injure the artery wall leading to more scarring and disease. Approximately 21 percent of stent placements clog up again within six months (called restenosis) and about 60 percent of arteries treated by angioplasty and stenting will undergo restenosis eventually. Additionally, there are serious risks associated with these procedures including bleeding complications, heart attack, stroke, and death.

Another important reason is that the largest, most obstructive plaques are not the most likely ones to rupture and cause a future heart attack. Since atherosclerotic plaque blankets many areas throughout the vasculature, compressing or removing the most obstructive portion does not address the rest of the plaque deposits, especially those non-obstructive plaques which are soft and unstable, contain many inflammatory cells and not as calcified. This is the type of plaque which has more of a propensity to rupture, leading to clot formation and a heart attack. Angioplasty and stenting procedures leave the major burden of disease intact, and therefore the potential for future heart attack remains unchanged.

Angioplasty or stenting is appropriate and can be lifesaving in emergency situations, for immediate clearing of an artery and restoration of blood flow during a heart attack. But, except in rare cases, for stable patients, the research suggests that there is no benefit. Because of COURAGE and similar studies, the American Heart Association and American College of Cardiology published guidelines for appropriate use to help reduce the number of inappropriate PCI procedures. The American Heart Association recommends medical therapy and lifestyle changes for first-line treatment in most cases of stable heart disease.

I counsel my patients about nutritional and lifestyle interventions, namely a nutrient-dense, plant-rich diet with a low glycemic load. Research has documented the dramatic effectiveness of a diet rich in natural plant foods for improving risk factors, reducing or eliminating the need for medications, and reversing heart disease. Yet cardiologists often do not inform their patients about this approach.

If you have heart disease, understand that lifestyle changes are an effective treatment strategy. Superior nutrition is an intervention that has no risk and no side effects – just side benefits, such as weight loss and prevention and reversal of diabetes and prevention of common cancers. 

Sources:

Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007, 356:1503-1516.

Desai NR, Bradley SM, Parzynski CS, et al. Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention. JAMA 2015, 314:2045-2053.

Esselstyn CB, Jr. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). Am J Cardiol 1999, 84:339-341, A338.

Finn AV, Nakano M, Narula J, et al. Concept of vulnerable/unstable plaque. Arterioscler Thromb Vasc Biol 2010, 30:1282-1292.

Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990, 336:129-133.

Sedlis SP, Hartigan PM, Teo KK, et al. Effect of PCI on Long-Term Survival in Patients with Stable Ischemic Heart Disease. N Engl J Med 2015, 373:1937-1946.

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