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In a groundbreaking development, the focus in preventing heart disease has shifted towards root cause prevention, emphasising an anti-inflammatory, nutrient-rich diet, regular movement, stress management, adequate sunshine, sleep, and toxin avoidance. This approach is supported by numerous studies, including the COURAGE and ISCHEMIA trials.
The COURAGE and ISCHEMIA trials have shown that for individuals with stable coronary artery disease (CAD), the placement of stents does not reduce the risk of future heart attacks or death compared to optimal medical therapy and lifestyle management. In other words, stents do not provide a survival or heart attack prevention advantage for stable patients over medications and healthy lifestyle changes alone.
Medical management, including medications such as statins, anti-anginal drugs, blood pressure control, and lifestyle changes (diet, exercise, smoking cessation), effectively manage stable CAD and reduce symptoms and risk. The European Society of Cardiology (ESC) and the American College of Cardiology recommend stents mainly for patients with significant ischemia unresponsive to medical treatment, not routinely for stable patients.
The ISCHEMIA trial, a massive, international study designed to settle the question of whether stents are beneficial for people with stable heart disease, did find a modest improvement in exercise capacity in the group that received stents. However, this improvement was not significant enough to change clinical practice.
It is crucial to note that most heart attacks occur due to the rupture of unstable plaques, which are not typically stented. The myth that stents prevent heart attacks can trap people in a cycle of unnecessary procedures, false reassurance, and ongoing risk. If a person is not having a heart attack, a stent will not help them live longer.
The best way to avoid a heart attack is not to wait until the artery is clogged enough for a stent but to stop the disease process entirely. The use of stents in people with stable heart disease should be carefully considered and balanced against the potential risks and costs.
Evidence-based supplements and targeted lab testing can also play a role in heart disease prevention. Remember, a stent is a tiny mesh tube used to prop open an artery after a blockage has been widened with a balloon. While it can save a life during a heart attack, its role in preventing heart attacks in stable heart disease is limited, serving mainly as a symptomatic treatment or emergency intervention.
Sources:
[1] COURAGE Trial Investigators. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;357(23):2257-2266. doi: 10.1056/NEJMoa0657139
[2] American Heart Association. Stable coronary artery disease. https://www.heart.org/en/health-topics/stable-coronary-arthtery-disease
[3] European Society of Cardiology. Guidelines for the diagnosis and management of chronic coronary syndromes in patients stabilised on dual antiplatelet therapy. https://www.escardio.org/guidelines-surveys/guidelines/acute-coronary-syndromes/percutaneous-coronary-intervention/2019
[4] ISCHEMIA Trial Investigators. ACCF/AHA/SCAI/AATS/PCNA/SCA Guideline on Percutaneous Coronary Intervention for Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Society for Cardiovascular Angiography and Interventions, the American Association for Thoracic Surgery, the Preventive Cardiovascular Nurses Association, and the Society of Cardiovascular Anesthesiologists. J Am Coll Cardiol. 2021;77(17):1989-2039. doi: 10.1016/j.jacc.2021.03.005
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