Optimal Medical Care as Effective as Stents and Bypasses for Preventing Heart Attacks

Common heart procedures such as cardiac stent procedures and coronary bypass surgery are no better at heart attack prevention or lowering the risk of death in people with stable coronary artery disease (CAD) than a plan of medications and healthy lifestyle changes. That’s the result of a large, federally funded clinical trial called one of the most important in cardiology. The findings could reshape medical practice, spare many patients from unnecessary surgery, and save hundreds of millions of dollars in healthcare costs each year.

While stents for blocked arteries and bypasses can be lifesaving during an active heart attack, they treat only a small part of the body’s more than 60,000 miles of blood vessels. For people without urgent symptoms, excellent medical care and better daily habits treat the entire arterial system at a fraction of the cost — about $25,000 for a stent and $45,000 for a bypass. Here’s a closer look at the study and what it means for millions of Americans in need of effective coronary artery disease treatment.

What was the purpose of the study?

The $100 million ISCHEMIA trial was designed to compare two treatment options for ischemia. This is reduced blood flow to the heart caused by plaque buildup inside the arteries that supply it with blood. The condition is known as CAD, ischemic heart disease, or coronary heart disease. It is the most common form of cardiovascular disease and the leading cause of death for men and women in the United States.

In some cases, CAD leads to stable angina, chest pain or pressure that appears with exercise or emotional stress. Unstable angina, on the other hand, is an emergency that often strikes at rest. It is often caused by blood clots from a ruptured plaque deposit, creating a high risk for a heart attack if untreated.

How was the study conducted?

The trial was funded by the National Heart, Lung, and Blood Institute and involved 5,179 people from 37 countries. All had moderate to severe ischemia. This was more than twice the size of any earlier study of its kind. About two-thirds had frequent or daily angina at the start. The rest had no chest pain. About 40% had diabetes. The median age was 64.

All participants received optimal medical therapy (OMT). This included cholesterol-lowering statins, low-dose aspirin, blood pressure drugs, and other medications, along with lifestyle advice to help them adopt healthier habits. Half the patients also had coronary angiography, an invasive x-ray test to check blood flow. If needed, they were treated with heart stent benefits from stent placement or cardiovascular surgery such as bypass to improve circulation.

The other group stayed on OMT alone. One man in this group told The Washington Post he switched to a mostly vegan diet, took his medications, and exercised regularly with an elliptical machine, hiking, and golfing. He said he felt much better, stayed active, traveled, and was glad to have avoided surgery.

The OMT-only group received invasive treatment only if symptoms worsened or they had a heart attack. The invasive group took strong anti-clotting medications for six to twelve months after surgery. The stents used were coated with drugs to lower the risk of new blockages.

How well did the treatments work?

Participants were followed for up to seven years. Researchers tracked five key outcomes: heart attack, death from cardiovascular causes, resuscitation after cardiac arrest, or hospitalization for unstable chest pain or heart failure. In the end, there was no difference in these outcomes between the OMT and invasive groups.

Six months into the study, the invasive group had a slightly higher rate of heart attacks than the OMT group (5.3% vs. 3.4%). Four years later, the pattern reversed, with a slightly higher rate of cardiovascular events in the OMT group (13.9% vs. 11.7%). By the end, the rates for heart attacks, cardiovascular deaths, and other events were nearly the same. About 14% in each group experienced cardiovascular issues during the study, which began in 2012.

One difference was in relief from chest pain. A year after treatment, half of those treated invasively were free from angina, compared to 20% in the OMT group. For those without angina at the start, there was no change in quality of life after procedures.

What did the researchers conclude?

“Our results suggest that regular use of invasive procedures was not better at reducing the risk of major cardiovascular events or death than optimal medical therapy,” said Dr. Judith Hochman, chair of the ISCHEMIA trial, at the American Heart Association’s annual meeting.

“Patients who had frequent symptoms at the start and underwent procedures felt better and had fewer symptoms over time,” she added. Dr. Hochman is a professor of medicine and senior associate dean for clinical sciences at NYU Langone Health.

Dr. David Maron, the study’s co-chair and director of preventive cardiology at Stanford University, said, “We recommend all patients take proven medications, stay active, eat a healthy diet, and quit smoking.”

How this fits with earlier research

The results match earlier findings, including the 2007 COURAGE trial, which also found OMT to be as effective as invasive procedures for preventing heart attacks and deaths from cardiovascular causes. A 2012 review of eight randomized clinical trials found that in people with non-acute CAD, stents did not offer added benefit over medical care in reducing death, heart attack, repeat procedures, or angina.

What it means for patients

The ISCHEMIA study suggests many of the one million Americans who have stents or bypass surgery each year could be treated effectively with OMT, avoiding surgical risks and high costs. About one-third of these procedures are for people with stable CAD. With advances in medications, many in this group can be treated safely without surgery. For many, the right combination of lifestyle changes, medical care, and coronary artery disease treatment offers the same protection as surgery.

FAQs

Can you still have a heart attack after a triple bypass?

Yes. New blockages can develop, or bypass grafts can close over time.

Is a stent or bypass better for a heart attack?

It depends on the case. Both can save lives during an active heart attack.

What is the survival rate for heart bypass surgery?

Most patients survive the surgery. Outcomes have improved with modern techniques and care.

Can you still have a heart attack if you have stents?

Yes. Blockages can form elsewhere, so ongoing care is important.