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A new medical study questions whether the hundreds of thousands of Americans with clogged heart arteries who choose to implant stents to relieve chest pain will actually feel any benefits. The study, recently published by The Lancet, found that while the mesh wire did improve blood flow, patients were still hurting. Dr. Ajay Kirtane, director of Cardiac Catheterization Laboratories at Columbia University Medical Center, joins Hari Sreenivasan to talk about its implications.
A new medical study is casting doubt on a heart procedure used by hundreds of thousands of Americans every year. The study, published this week by The Lancet, found that stents, the metal wires implanted to unblock heart arteries, do improve blood flow but do little to ease chest pain. Dr. Ajay Kirtane is the director of Cardiac Catheterization Labs at Columbia University Medical Center here in New York and he joins me now in the studio to discuss this study. First of all, how significant was this study?
DR. AJAY KIRTANE:
It's an interesting study. It was only 200 patients in cardiovascular disease trials, we're used to much larger studies, but it had a novel concept and that was the concept of a stent procedure and a placebo stent procedure, sometimes called a sham. What's interesting about it is that patients with milder symptoms and disease in only one of the three heart arteries were aggressively managed with medicines. And then after some time were actually randomized to one of those two techniques. And about six weeks later, they were reassessed for not only their symptoms, but also how much they could exercise. And I think you characterized it exactly right. There was an improvement in flow in the arteries, not only in the cath lab but then also at follow-up their stress test results were normalized. They actually could exercise a little bit longer than they could at baseline. But that increment in exercise was not that dissimilar to the patients who got the placebo procedure.
So are you surprised by that finding?
You know, first I was. But when one looks at studies in any part of medicine you have to really look carefully at the types of patients that were enrolled in the study. And what's interesting here is that the medicines that were used to treat these patients upfront and the fact that they only had single-vessel disease should actually cast this in a different light. And what I mean by that is that at baseline these patients had only about one episode of chest pain a month. In addition, their ability to exercise was pretty good. In fact if you measure something called the VO2 max — you often see athletes with masks on, they're measuring VO2 max — that was basically the same as patients that don't have any heart disease at all at the same age.
So it was kind of almost a healthier population than a lot of people who get stents for severe chest pain or much more advanced disease.
Exactly and I think that's one of the problems that I had at least with some of the initial coverage of this story, in that it generalized this study findings to a broad swath of patients, with patients with more severe disease and even those that had more severe symptoms.
Given the amount of money that's in these procedures in hospitals around the country it's almost become a fairly, a standard of care. You know, you are at a facility that does the research, you're up on the latest stuff. So is there, are there so many extra sort of stent prescriptions, so to speak? Are there procedures that might not be necessary, where perhaps medical treatment could work first or exercise, eat right, that kind of stuff, could help?
Absolutely. I think the key thing is that you have to treat the right patient. So in the hospital, I work at New York Presbyterian Hospital here in the city, and in that setting, for hospitalized patients with heart attacks and acute chest pain, there's no, there's no doubt that stents work in those patients. But for patients that are more stable, like those in this study who had chest pain for an average of nine months before that was stable, especially if you have milder disease and milder symptoms, medicines are very very effective in that setting. Oftentimes patients sort of in some respects get very concerned when you tell them they have a heart artery blockage. But if it doesn't obstruct flow, and is not in a dangerous location, then medicines are often the best effective therapy initially.
So what happens now? I mean this is a group of 200 people. Are there going to be other researchers that say, well, let's look at different types of patients. Let's look at larger patient populations and see whether this is effective or not?
I do think so. I mean this is clearly a springboard for further studies. I think the investigators to their credit have shown that you can do this type of design, which is a little bit novel to do the placebo procedure. But I think most importantly for the way we treat patients we have to be patient-centric and treat the patient not just the angiogram or what we see in the cath lab.
All right, Ajay Kirtane from Columbia University thanks so much.
Thanks for having me.
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