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Surgery should not be angina patients' first option

Monday January 17th 2022

Doctors should treat stable angina patients with medical therapies before recommending stents or bypass surgery, experts have stated.

In an article in the latest edition of *The Lancet*, researchers from the UK and USA say by better understanding the mechanisms that can cause angina – and targeting medical treatment to the specific underlying cause – the outcomes for stable angina patients are similar to those who undergo a surgical procedure straight away.

They say it is appropriate to test different treatments over three to six months in all but the most severe symptomatic patients before proceeding to surgery, adding that managing lifestyle changes and medical interventions are essential to reducing the risk of cardiac events.

The recommendations could potentially prevent risky and expensive coronary intervention for patients living with stable angina, they add.

Author Professor Juan Carlos Kaski, from St George’s, University of London, said: “Our work encourages clinicians presented with angina patients to consider that stable angina is a complex situation that might not necessarily be linked to an obstructed coronary artery, with other mechanisms such as coronary spasm and microvascular dysfunction also being responsible for symptomatic disease.

“It is in the patient’s best interest to understand the underlying causes of disease and treat with targeted medical therapies in the first instance. Only when these treatment options fail or if the patient condition requires it, should coronary intervention with surgery or stents be considered as the next step.”

The authors say doctors should take time to assess their patients for the mechanisms behind their stable angina, such as by testing blood pressure and heart rate, provide the appropriate treatment and assess the response to treatment over weeks and months.

They highlight an international trial in more than 5,100 such patients, which resulted in no additional risk to stable angina patients after waiting several months to assess treatment efficacy and using medicines before moving onto surgery if there was no improvement.

First author Professor William E. Boden, of Boston University School of Medicine, said: “It is important for practitioners to be both patient and vigilant in assessing the effectiveness of treatments for angina using a more conservative approach to management.

“Clinical practice guidelines endorse such a measured treatment approach since the great majority of stable angina patients, if given sufficient time to allow effective medicines to work, will experience an improvement in the frequency of angina episodes over a period of several weeks to months. There is universal agreement that such a prescriptive approach and watchful waiting is both safe and effective in determining if a heart procedure is necessary”.

Boden W E et al. What constitutes an appropriate empirical trial of antianginal therapy in patients with stable angina before referral for revascularisation? *Lancet* 13 January 2022

[abstract]

Tags: Heart Health | North America | UK News

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