Heart failure

Thousands of NHS heart failure patients at risk of stent operations that don’t benefit them

Thousands of NHS heart failure patients undergo unnecessary stent surgery each year, putting them at risk of life-threatening complications with no hope of benefit, experts have warned.

For years, cardiologists have thought that implanting tiny metal tubes into clogged heart arteries was an effective treatment for the condition that affects one million people in the UK.

Now, a landmark British trial has shown the procedure did not improve symptoms or survival in this group. Instead, he suggests patients should be offered medication in order to control problems and improve quality of life.

The findings are expected to influence international guidelines on how patients with heart failure are treated.

Around 100,000 stents are fitted each year in the UK. Most are given when patients suffer a heart attack to prevent a second one – and used like this, they are a proven lifesaver, dramatically improving health and preventing premature death.

But it is estimated that one in 20 stent procedures are performed to treat heart failure.

Around 100,000 stents are fitted each year in the UK. Most are given when patients suffer a heart attack to prevent a second one – and used like this they are a proven lifesaver, dramatically improving health and preventing premature death

Around 100,000 stents are fitted each year in the UK.  Most are given when patients suffer a heart attack to prevent a second one - and used like that they are a proven lifesaver, dramatically improving health and preventing premature death (pictured posed by model)

Around 100,000 stents are fitted each year in the UK. Most are given when patients suffer a heart attack to prevent a second one – and used like this they are a proven lifesaver, dramatically improving health and preventing premature death (pictured posed by model)

Unlike a heart attack, which occurs when the blood supply to the heart is suddenly blocked, heart failure is a chronic condition in which the heart can no longer pump effectively because the muscle has weakened. Around 200,000 Britons are diagnosed with the disease each year – and there is no cure.

Only half of heart failure patients live more than five years after their diagnosis, and the symptoms, which include extreme shortness of breath and fatigue, can be debilitating.

Narrowing of the arteries – a condition called coronary artery disease – is a common cause, so doctors hoped stents, which act like a scaffold to hold the blood vessel open, might help.

Stents are implanted using a thin, flexible wire called a catheter, inserted through a small incision in the groin or wrist. This is threaded through the blood vessels to the heart. Although it is considered a very safe operation, complications can occur. A new stent can cause blood to clot, leading to a heart attack or stroke in 1 in 500 cases. But this small risk has been shown in clinical trials to be far outweighed by the protective benefits when given to heart attack patients. Although the new study did not find an increased risk, in terms of post-surgical complications, in heart failure patients receiving stents, it did find that the procedure does not benefit patients.

In the study, 700 heart failure patients were divided into two groups: half received stents and drug treatments, the other half received drug treatments alone. They were then followed for up to eight and a half years. The results for the two groups were almost exactly the same: just over a third of the patients were hospitalized or died.

Professor Divaka Perera, Consultant Cardiologist at Guy’s and St Thomas Hospital, who led the research, said: ‘For years doctors have thought that stent surgery allowed patients with heart failure to feel better and live longer. But we now have definitive proof that this is not the case.

“All stent procedures – and surgery in general – carry small risks, and these complications can even be fatal, so it’s important that we don’t give them away unnecessarily.”

It is hoped that the results of the trial, presented at the Congress of the European Society of Cardiology last month and published in the New England Journal Of Medicine, will lead to a change in the guidelines. The new study adds to a growing body of evidence that has emerged in recent years, casting doubt on the benefits of stents in other patient groups.

Colored x-ray of a stent (white) that has been implanted in a coronary artery at the anterior descending artery - in a left anterior oblique view of the heart

Colored x-ray of a stent (white) that has been implanted in a coronary artery at the anterior descending artery – in a left anterior oblique view of the heart

In 2019, a major international trial led by Stanford Medicine and New York University found that implants were no better than drugs alone at preventing first heart attacks, even in patients with severe coronary artery disease.

In the first two years, those who received stents were more likely to suffer a heart attack than those who received only drugs. The procedure, however, reduced chest pain related to angina, another problem caused by heart disease.

In recent years, there have been a number of advances in the treatment of heart failure. Canagliflozin, dapagliflozin and empagliflozin – three drugs originally used to treat diabetes – have been shown to significantly improve symptoms in some patients with heart failure.

The benefits have been seen in people with heart failure with reduced ejection fraction, or HFrEF, one of the two main types of disease and affecting some 500,000 adults in England and Wales.

Research published last year suggested that pirfenidone, which reduces lung scarring caused by Covid, may also benefit patients with the other most common type, heart failure with preserved ejection fraction, or HFpEF. .

Despite this, nothing currently prevents the disease from getting worse, and for these patients the only hope will be a heart transplant.

Some, like Nick Hartshorne-Evans, a heart failure patient and founder of the Pumping Marvelous campaign group, are reluctant to see stent therapy “taken off the table”. He said: “The study showed some improvement in quality of life during the first year after stent treatment. If cancer treatment gives a patient a few months of better health, we would consider that a positive, so why not the same with this? »

However, Professor Perera said he hoped heart failure patients would no longer receive unnecessary stents and called for investment in research into new treatments. He added: “New drugs have helped a lot, but the truth is that this disease still shortens many lives and we need to keep looking for ways to help patients feel better and live longer.”