Doing our patients more harm than good

Earlier this week, I was invited as a resource speaker in an innovative CME (continuing medical education) activity of the University of Padova in Italy organized by Prof. Sabino Iliceto, the head of the university’s Department of Cardiovascular Medicine. The sessions were taped and will be broadcast as CME “webinars” in selected medical audiences of heart specialists in Asia-Pacific and other parts of the world.

The university, which was founded in the early 13th century, is one of the oldest in Europe, and remains one of Italy’s important resources of cutting-edge research and education.

Centuries-old rooms

Many of the university’s centuries-old rooms have been preserved, and I was particularly enthused to see its original pathology laboratory wherein the cadaver table was at the lowest level at the center. Four levels of circular galleries spread outward as in an arena, such that the students standing behind the wooden railings could all watch the professor’s assistants dissecting the cadaver as the professor explained each organ being dissected.

Of course, this old pathology laboratory is no longer being used, and the university has such a modern version, but for a moment I thought I was thrown back in time, straining my eyes to see the dissected parts of the human anatomy being studied with only big candles illuminating the cadaver’s table. It has electric candles looking like real candles of old to simulate the medieval ambiance.

Anyway, the session I was invited to be a panelist and resource speaker tackled the treatment of coronary artery disease (CAD), a condition wherein one experiences chest pains due to the narrowing of the heart arteries. CAD is a prevalent problem worldwide, causing heart attack and heart failure. It remains a leading killer in our country.

Conservative vs modern

We dissected the pros and cons of conservative medical treatment (optimizing diet, exercise and medicines) versus aggressive surgical intervention (either heart bypass surgery or angioplasty with stenting) in patients with stable CAD, which comprises the majority of cases.

Fixing the clogged arteries by angioplasty with stenting can now be done on an outpatient basis in some centers here and abroad. Because of the available technical expertise and state-of-the-art equipment and catheters, it has seen an upsurge in the last decade despite recommendations from clinical practice guidelines issued by various cardiovascular societies in the world to temper its overuse, and to recommend it only when strongly indicated.

Professor Iliceto, who chaired our panel discussion himself, and the other members of our panel—Prof. John Camm, a world-renowned cardiologist from the United Kingdom, and Prof. Antonio Zaza, an equally distinguished scientist and cardiac electrophysiologist from Milan, Italy, and myself—were of the consensus that a good number (I estimated it to be a third) of all cases being subjected to angioplasty with stenting could be better managed with optimal medical therapy.

I presented several recent publications showing that  patients with stable coronary artery disease, wherein the chest pains and other symptoms are not really activity-limiting and the amount of heart muscles which are ischemic (lacking in oxygen) are not more than 10 percent of the heart area, are better managed with conservative medical treatment. They usually have only one or two heart arteries which are occluded.

If we do angioplasty with stenting in these patients with one or two clogged arteries, they paradoxically fare worse, have a higher risk to develop a heart attack and a higher risk to require bypass surgery later on. This is the classic case of the treatment making the patient worse rather than better.

Aggressive intervention

Having said that, let me clarify though that there are some types of heart artery blockages which will really require aggressive intervention or revascularization—fixing the clogged arteries by surgery or using catheters and stents. The aggressive intervention is opted to improve long-term survival.

Cases include the blocking of the main artery (left main artery disease), a major artery (proximal left anterior descending artery) or three or more arteries (triple or multivessel disease), especially if there are signs of heart failure (weakening of the heart muscles). In such cases, an aggressive approach is justified to reduce the risk of premature death on the long run.

If revascularization is indicated, deciding whether to do angioplasty with stenting or doing outright bypass surgery is another tricky question, too. As a general rule though, surgical bypass is “more durable” than angioplasty with stenting, and may be more practical in multiple vessel disease, especially in diabetic patients, wherein the narrowing of the heart artery tends to be progressive.

Stenting only addresses the current or existing lesion, while bypass surgery may be good enough to address even future lesions that might develop later on. Hence, it’s said to be “more durable” than stenting.

With all due respect to my colleagues, I believe that in many, if not the majority of cases, of stable coronary artery disease, with an occlusion of just one or two heart arteries, optimal medical treatment is the more rational treatment approach. Let’s not subject our patients immediately to angioplasty with stenting. Let’s give medicines a try first.

Newer agents

Professors Camm and Zaza presented newer agents like ranolazine (Ranexa) that can effectively and safely relieve the patient’s chest pains even without angioplasty or surgery. We also have  anti-ischemic medicines that we can try like beta-blockers, nitrates and calcium antagonists. Cholesterol-lowering drugs, specifically statins, angiotensin converting enzyme inhibitors, the good old aspirin or other blood-thinning drugs, can also do wonders to stabilize our patient’s condition.

The old concept—that if you could demonstrate a clogged artery, do angioplasty with stenting immediately—is no longer evidence-based and definitely not to the best interest of the patient. We might be doing our patients more harm than good. And I’m sure we all hate doing that.