A Review and Opinion article published in The Lancet has recommended that clinicians seek to understand the mechanisms behind angina in stable patients and waiting to see if intensification of medical therapies works before proceeding to coronary revascularisation.

The paper, authored by researchers from the UK and USA, reviews evidence from multiple studies comparing the use of medicines based on patient assessment, against interventions, such as coronary stent or heart bypass surgery.

The researchers propose that by better understanding the range of mechanisms that can cause angina and targeting medical treatment to the specific underlying cause, the outcomes for such stable angina patients are comparable to proceeding straight to a surgical procedure. The recommendations in the paper could potentially prevent the need for risky and expensive coronary intervention for the thousands of patients living with stable angina in the UK.

Current European and US practice guidelines recommend the use of medical therapies before moving onto revascularisation if symptom treatment fails. However, there is no clear line on what constitutes optimal treatment, with drugs being offered sequentially as first-line then second-line treatments by clinicians – trying one treatment first and moving onto others if not effective.

Instead, the authors propose that doctors take time to assess their patients for the mechanisms behind their stable angina, such as by testing blood pressure and heart rate, and then aligning the appropriate treatment based on this and assessing the response to treatment over a period of several weeks to months.

In fact, one recent large international trial** in over 5,100 such patients found no additional risk to stable angina patients in waiting several months to assess treatment efficacy and the use of other available medicines before moving onto surgery if there is no improvement.

The authors conclude that it is appropriate to test different treatments over the course of three to six months in all but the most severe symptomatic patients before proceeding to surgery. They assert that managing lifestyle changes and medical interventions are essential to reducing the risk of cardiac events such as heart attacks, whether a patient has received coronary intervention or not.

Professor Juan Carlos Kaski, author on the paper from St George’s, University of London, said: “Our work encourages clinicians presented with angina patients to consider that stable angina is a complex situation that might not necessarily be linked to an obstructed coronary artery, with other mechanisms such as coronary spasm and microvascular dysfunction also being responsible for symptomatic disease. It is in the patient’s best interest to understand the underlying causes of disease and treat with targeted medical therapies in the first instance. Only when these treatment options fail or if the patient condition requires it, should coronary intervention with surgery or stents be considered as the next step.”

Professor William E. Boden, first author on the paper, from Boston University School of Medicine, added that: “It is important for practitioners to be both patient and vigilant in assessing the effectiveness of treatments for angina using a more conservative approach to management. Clinical practice guidelines endorse such a measured treatment approach since the great majority of stable angina patients, if given sufficient time to allow effective medicines to work, will experience an improvement in the frequency of angina episodes over a period of several weeks to months. There is universal agreement that such a prescriptive approach and “watchful waiting” is both safe and effective in determining if a heart procedure is necessary”.

* Boden W E et al. What constitutes an appropriate empirical trial of antianginal therapy in patients with stable angina before referral for revascularisation? 2022. The Lancet. https://doi.org/10.1016/S0140-6736
** Maron DJ, Hochman JS, Reynolds HR, et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020;382:1395–1407.

Source: St George’s, University of London

Full bibliographic information
Boden W E et al. What constitutes an appropriate empirical trial of antianginal therapy in patients with stable angina before referral for revascularisation? 2022. The Lancet.