Every year 60,000 people in the UK are diagnosed with heart failure and many are treated with stents. In a large new study published in the New England Journal of Medicine, my colleagues and I found that these procedures are not necessary.
In heart failure, the heart muscle is weakened, leading to symptoms of severe shortness of breath that can cause premature death. The most common cause is clogged arteries that reduce blood flow to the heart muscle. This is known as coronary artery disease.
A person with heart failure is treated with medications and sometimes specialized pacemakers. Despite this treatment, many patients die prematurely or are hospitalized with worsening symptoms.
People with heart failure also sometimes have a procedure to insert a stent — a small metal tube used to unblock a coronary artery. Stents are placed in the heart arteries by a cardiologist through tubes inserted into the wrist or groin and guided by X-rays. Trials have shown that stents are a very effective treatment for people with heart attacks and angina, but their effects in patients with heart failure have remained uncertain.
Some cardiologists had noted improvements in patients’ symptoms and heart function after stent placement, but researchers couldn’t say whether these improvements were directly related to the stents, or could have happened to drugs anyway. Without proper research, treatment guidelines for the use of stents in patients with heart failure have varied, with the NHS advising against stent placement and European guidelines recommending it in certain patients.
In this latest study, the REVIVED-BCIS2 study, led by Professor Divaka Perera, we tested whether treatment with stents helped patients live longer or stay out of hospital. The trial was a collaboration of 40 NHS hospitals in the UK and ran from 2013 to 2020.
Patients could be included in the study if they had severely weakened heart muscle and extensive blockages of the coronary arteries. They also ordered specialized heart scans so that stenting could be targeted to the areas of the heart muscle most likely to recover.
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Seven hundred patients participated and half were randomly selected to receive stents, while all patients received standard treatment for heart failure. The patients attended follow-up appointments for up to eight years so that their health and heart function could be closely monitored.
On average 3.4 years after treatment, patients who received stents were just as likely as those who had not died or been hospitalized with heart failure, showing that the treatment was ineffective.
Heart scans and blood tests also showed no difference in the heart’s pumping power, supporting the main study findings.
Our study did show that patients who had stents had a better quality of life the first year, but after two years the difference disappeared and patients reported similar health. While there was no benefit to placing stents, there was also no sign that stents were causing damage.
No more research is needed
The results of the study mean that stents should not be used to treat patients with heart failure caused by coronary artery disease, unless they have another condition, such as angina or a recent heart attack.
Due to the design and number of patients involved in the study, the answer is clear and further research to answer this question is not necessary at this time. We will spend time reviewing the results to try to understand why stent placement did not work. Although no benefit was shown, the findings are important because they mean that patients with heart failure do not have to undergo unnecessary procedures. The costs of stenting procedures can also be redirected towards other treatments and better care for patients with heart failure.
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