Thousands of patients with heart disease may be denied the best chance of survival because of uncertainty over the most suitable treatment option, warns a cardiac surgeon in this week's BMJ.
Coronary artery disease occurs when artery walls become thickened by fatty deposits, leading to an inadequate blood supply to the heart. A procedure called 'revascularisation' improves blood flow and reduces the risk of death. There are two ways this can be done – by stenting or bypass surgery.
Coronary artery bypass surgery involves grafting healthy arteries and/or veins to the heart, while stenting involves the insertion of a stent (small tube) into blocked arteries.
Many cardiologists favour the less invasive stenting option and stenting procedures now outnumber surgery at least fourfold. But three studies published together in this week's BMJ question the clinical and cost effectiveness of stenting.
Two show that surgery is at least as effective, and probably more cost effective, than stenting over the medium to long term, while the third concludes that the benefit of stenting over medical or surgical treatment is "too small to justify its additional costs."
But despite these findings, practice is unlikely to change as many patients may still favour the less invasive approach of stenting, writes David Taggart, Professor of Cardiovascular Surgery at the University of Oxford in an editorial.
Not only does this approach risk higher rates of reintervention but, more importantly, it may also deny many patients with "multivessel" disease (who survive significantly longer after surgery compared with stenting) the prospect of a better long term outcome offered by surgery, he says.
These studies highlight the tension between the adverse economic implications of the phenomenal growth in stent procedures and the absence of an appropriate evidence base to support such a policy, he writes. It also highlights the dangers of individual practitioners rather than multidisciplinary teams making recommendations for stenting in patients with multivessel disease.
He believes that a multidisciplinary approach should be a minimum mandatory "standard of care" to ensure that patients are offered the most clinically appropriate treatment.