Aggressive Is Best for Older Heart Patients

Artery-opening procedures work better than drugs, study finds

FRIDAY, Sept. 21, 2001 (HealthDayNews) -- Older people -- 75 and up -- with the dangerous, chronic chest pain called angina do better with aggressive artery-opening treatments than with drug therapy, a Swiss study finds.

Angina happens when fatty deposits build up in heart arteries, narrowing them so that the heart muscle cannot enough oxygen-carrying blood. Mild angina can be managed with drug therapy, but more severe blockages require bypass surgery or angioplasty, in which a balloon is used to widen blood vessels.

The study was done because "previous randomized trials have focused on patients younger than 75 years of age," and those findings might not apply to older people, a group led by Dr. Matthias E. Pfisterer, a cardiologist at University Hospital in Basel writes in the journal The Lancet.

The Swiss trial included 305 patients, all 75 or older, who were bothered by their angina even though each was taking at least two drugs. Half of them were treated with more powerful drug therapy, while the others had either bypass surgery or angioplasty. Over the next six months, the doctors assessed the patients' quality of life -- general health, vitality, freedom from pain -- and kept track of "major adverse cardiac events" -- hospitalization, heart attacks and death.

All the patients said their quality of life improved, but the improvement was much greater for those who had artery-opening procedures, the report says. And the difference in the incidence of major cardiac events was striking -- 49 percent for the drug treatment patients, 19 percent for those who had the artery-opening procedures. There were fewer deaths in the drug therapy group, but the difference was not statistically significant, the researchers say.

The best way to treat older patients with severe angina is to do angiography, a test to determine whether they are eligible for artery-opening procedures and to recommend those more aggressive procedures for all eligible patients, the researchers conclude.

Dr. Richard A. Stein, chief of cardiology at the Brooklyn Medical Center and a spokesman for the American Heart Association, agrees with that conclusion. "If you can improve the quality of life by reducing pain after drug treatment has failed, it's all right to do surgery," he says.

Stein says he does not like the alternative of watchful waiting to see whether drug treatment is enough to give a good quality of life. "The answer from this study is that the patients are not becoming pain free. You allow them to go on with a reduced quality of life for a prolonged period."

But Dr. Michael W. Rich, associate professor of medicine at Washington University in St. Louis, has a different view, based in part on the risk of artery-opening procedures. "You could argue that it is reasonable to increase the patients' medication, and if they continue to have problems, do revascularization [artery-opening] at a later time," he says.

The Swiss study is valuable because "it does break new ground," Rich says. "It is the first study of this type done in this age group. It has been a major question whether older patients benefit from revascularization as [much as] younger patients do. This study is of a sufficient size to provide us with some insight on the benefits of revascularization in this population."

What To Do

The patient should take part in the decision, Rich says. "The choice is easily discussed with the patient," he says. "With angioplasty or bypass surgery, there is a small but definite risk, but if it is successful, there is good evidence that it will improve symptoms and improve quality of life. I don't think it's necessary for the physician to mandate a decision. You can present the options, and discussing the pros and cons is a reasonable approach."

You can learn all about angina and its treatments from the American Heart Association. Or, get the latest news from the Heart Information Network.

Want to find out how healthy your heart is? Start by taking this quiz from the Minneapolis Heart Institute Foundation.

SOURCES: Interviews with Richard A. Stein, M.D., chief of cardiology, Brooklyn Medical Center, N.Y., and spokesman, American Heart Association; Michael W. Rich, M.D., associate professor of medicine, Washington University School of Medicine, St. Louis, Mo; Sept. 22, 2001, The Lancet
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