Medicine or medical interventions like surgery or stents to remove blockages in the heart ― which is the approach that delivers better patient outcomes? This debate has been raging in the medical community for over two decades now.

But a recent study has found that the outcomes were not really different between people with stable heart disease who were treated through a combination of medicine and lifestyle changes, compared to those who were put through a surgery or stenting procedure (where a wire-like mesh is inserted to unblock the artery). The findings from the ISCHEMIA study, backed by the United States Government were presented at the American Heart Association (AHA) meeting in Philadelphia, over the weekend.

Coming at a time when questions are being asked internationally and in India on whether patients were being put through unnecessary procedures, especially in the case of stents, the study could help refine the approach to treating stable heart disease, say doctors. And this, in turn, would result in cost savings for patients or the healthcare system, depending on who picked up the hospital bill.

“The ISCHEMIA trial failed to show that routine invasive therapy was associated with a reduction in major adverse ischemic events, compared with optimal medical therapy among stable patients with moderate ischemia,” the study said. In other words, invasive therapies like a surgery or stent procedure in the given condition did not necessarily improve the quality of life for a patient or protect them from a heart-attack, explain heart-specialists.

The study results did not apply to patients with current/ recent, acute coronary syndrome, highly symptomatic patients or those with blocks in the left main coronary artery, the study said.

Dr Srinath Reddy, former head of the cardiology department at All India Institute of Medical Sciences (AIIMS) and President, Public Health Foundation of India, explains the study suggests that surgery or stents need not be the first port of call for patients with a stable heart disease, if medication and a lifestyle change could help. “But there is a caveat, in that the first level of medical management should be good and there should be proper follow-ups after that,” he told BusinessLine.

The study findings should help fine-tune existing guidelines on the approach to treating a stable heart disease, but it also needs to be assessed depending on the individual situation, for instance, if the patient is from a remote part of the country where follow-ups are difficult, he added. The latest study suggests a “prudent” approach, he summarises.

Dr Aashish Contractor, Director (Rehabilitation and Sports Medicine), Sir HN Reliance Foundation Hospital, says, “The study reinforces the understanding that for stable heart disease, medical management and lifestyle changes are the mainstay therapy.”

Experts however, caution that the study should not give a false sense of confidence to patients, but should enlighten them that not all conditions need an intervention. There are situations in which intervention is the best way forward, such as in the case of a heart attack, says a doctor who did not want to be named. So the selection criteria is extremely important, he adds.

Much, of course, will depend on how doctors accept these findings and change the way they approach stable heart disease, say members of the fraternity.

Info-box: ISCHEMIA trial

# The International Study of Comparative Health Effectiveness With Medical and Invasive Approaches was funded by the National Heart, Lung and Blood Institute.

# Involved 5,179 enrollees, followed up over three years, median patient age was 64 years.



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