health right now

Less is More
Why many interventions are unnecessary.

dies have shown that even many doctors are not aware of this fact!

S
DR VIKAS SAINI is a clinical cardiologist and researcher at Harvard Medical School and Harvard School of Public Health. He is president of the Lown Cardiovascular Research Foundation in Boston. Write to him at vikas.s@preventionindia. com.

For years we were considered heretics, although thoughtful people recognised that we made sense

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What Clinical Research Shows

TOP: PHOTOGRAPH BY: RITESH SHARMA; BOTTOM: SHUTTERSTOCK/INDIAPICTURE

econdary prevention means preventing heart attacks or death after a diagnosis of heart disease has been made. Can coronary bypass surgery or angioplasty with stenting be called secondary prevention? The short answer is no. For over 40 years Dr Bernard Lown and his small trickle of students at Harvard University have maintained that there is too much surgery and stenting going on to be justified on medical grounds. We showed that patients with coronary disease but stable symptoms could be managed very well with medicationessentially all the medications Ive discussed in recent columns.

more often than the mainstream realised. In the last five years, as large randomised trials such as the COURAGE and BAR-2D trials have been done, there has been a recognition that what weve said for decades may be true for most coronary patients: surgery and stenting can be reserved as a last resort for unstable symptoms when medical therapy fails. These trials have shown that patients dont generally live longer or have fewer heart attacks with surgery or a stent. They tend to have fewer symptoms and need fewer meds, But even this is often an advantage that lasts only a year or two, after which the two lines of treatment become equivalent. According to several studies, most patients with stable angina going for a stent were not aware that it was not going to make them live longer or prevent a heart attack. Some stu-

When Invasive Procedures are Needed

In our experience, medical therapy fails at a low, steady rate over many years. Although an infrequent occurrence, when it happens, such as during a heart attack, a stent can be life-saving. Thus for patients with angina, the most important thing to track is the stability of the symptoms. If the same walk at the same pace begins to cause chest discomfort at an earlier and earlier time, it can be a cause for concern. Quite often, an adjustment of medication can restore the previous balance. When it does not, a closer evaluation is indicated. When angina is accelerating particularly fastover weeks or daysor occurring at rest, it needs an urgent evaluation, and often a cardiac catheterisation, also known as a coronary angiogram to determine the right treatment. A few weeks ago I presented our outcomes with over 12 years of

follow-up in patients who came to us seeking a second opinion after being told by another physician to have surgery, and who then continued using our approach. Mortality rates in our patients treated conservatively were comparable over this long period of follow-up with the rates that have been reported with bypass surgery in randomised trials. Rates of heart attack and need for later surgery were low too. The lessons of our experience indicate that careful medical care can defer more invasive (and more expensive) tests and treatments in the majority of patients with coronary heart disease. Increasingly in the US, more physicians are beginning to adopt the perspective that quite often less is more.

Surgery and stenting can be reserved as a last resort for unstable symptoms when medical therapy fails.

PREVENTION MAY 2012