Thousands of NHS heart failure patients are being given unnecessary stent surgery every year, putting them at risk of life-threatening complications without any hope of benefit, experts have warned.
For years cardiologists thought that implanting the tiny metal tubes in 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 doesn’t improve symptoms or survival for this group. Instead, it suggests, sufferers should be offered medication in order to control problems and improve quality of life.
The findings are expected to influence international guidelines on the way heart failure patients are treated.
About 100,000 stents are fitted every 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, drastically improving health and preventing an early death.
But an estimated one stent procedure in 20 is carried out to treat heart failure.
About 100,000 stents are fitted every 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, drastically improving health and preventing an early death
About 100,000 stents are fitted every 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, drastically improving health and preventing an early death (picture posed by model)
Unlike a heart attack, which happens when the blood supply to the heart is suddenly blocked, heart failure is a chronic condition in which the heart can no longer pump efficiently because the muscle has become weakened. About 200,000 Britons are diagnosed with the condition every year – and there is no cure.
Just half of heart failure patients live more than five years after their diagnosis, and the symptoms, which include extreme breathlessness and fatigue, can be debilitating.
Narrowed arteries – a condition called coronary heart disease – is a common cause, which is why doctors hoped stents, which act as a scaffold to keep the blood vessel open, might help.
Stents are implanted using a fine, flexible wire known as a catheter, inserted via a tiny cut in the groin or wrist. This is threaded through blood vessels toward the heart. While it is considered a very safe operation, complications can occur. A new stent can cause blood clotting, resulting in a heart attack or stroke in one in every 500 cases. But it has been shown in clinical trials that this small risk is far outweighed by the protective benefits when given to heart attack patients. While the new study didn’t discover any increased risk, in terms of post-surgical complications, in heart failure patients given stents, it found the procedure does not benefit patients.
In the study, 700 heart failure patients were divided into two groups: half given stents and drug treatments, half given drug treatments alone. They were then followed for up to eight-and-a-half years. The outcomes for both groups were almost exactly the same: just over a third of patients were either hospitalised or died.
Guy’s and St Thomas’ Hospital consultant cardiologist Professor Divaka Perera, who led the research, said: ‘For years, doctors thought stent surgery made heart failure patients feel better, and live longer. But we now have definitive proof that this isn’t the case.
‘All stent procedures – and surgery in general – carry small risks, and these complications can even be fatal, so it’s important we do not give them unnecessarily.’
It’s hoped the results of the trial, presented at last month’s European Society for Cardiology Congress and published in the New England Journal Of Medicine, lead to a change in guidelines. The new study adds to a growing body of evidence that has emerged in recent years, casting doubt over the benefit of stents in other patient groups.
Coloured X-ray of a stent (white) that has been implanted in a coronary artery at the level of the anterior interventricular 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 the implants were no better that medication alone in preventing first heart attacks, even in patients with severe coronary heart disease.
In the first two years, those given stents were more likely to suffer a heart attack when compared with those given only drugs. The procedure did however reduce angina chest pain, another problem caused by heart disease.
In recent years, there have been a number of advances in heart failure treatment. Canagliflozin, dapagliflozin, and empagliflozin – three drugs originally used to treat diabetes – have been shown to significantly improve symptoms in some heart failure patients.
The benefits were seen in those with heart failure with reduced ejection fraction, or HFrEF, one of the two main types of the condition and affecting some 500,000 adults in England and Wales.
Research published last year suggested that pirfenidone, which reduces lung scarring caused by Covid, might also benefit patients with the other most common type, heart failure with preserved ejection fraction, or HFpEF.
Despite this, nothing at present stops the disease eventually worsening, and for these patients the only hope will be a heart transplant.
Some, such as Nick Hartshorne-Evans, a heart failure patient and founder of the campaign group Pumping Marvellous, are reluctant to see stent treatment ‘taken off the table’. He said: ‘The study did show some improvement in quality of life in the first year after stent treatment. If a cancer treatment gives a patient a few months of better health, we would see that as positive, so why not the same with this?’
However, Prof Perera said he hoped heart failure patients would no longer be given unnecessary stents, and called for investment in finding new treatments. He added: ‘Newer drugs have helped a great deal but, the truth is, this disease still shortens many lives and we have to continue to look for ways in which we can make patients feel better and live longer.’