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New hope for patients with angina as stents proved to be an alternative to pain medication

Published: 27 November 2023

A trial funded by the NIHR Imperial Biomedical Research Centre has shown patients experiencing chest pain from reduced blood flow to the heart may benefit from having a stent implanted instead of chest pain medication.

Angina is chest pain caused by reduced blood flow to the heart muscles. People with angina can be at risk of a heart attack or stroke. A stent is a tiny device that helps keep a narrowed artery open in the heart.

A previous trial found, compared to painkillers, stents had no extra benefit on: 

  • symptoms such as pain 
  • ability to exercise
  • quality of life 

But these results may have been due to the chest pain medication these patients were taking during the trial. So the researchers recruited 301 patients across 14 sites in the UK into a second trial, ORBITA-2. The patients stopped taking their chest pain medication before receiving either: 

  • a stent, or
  • a placebo procedure

Patients continued taking aspirin and statins that reduce the risk of heart attack.

The researchers from Imperial College London and Imperial College Healthcare NHS Trust found that implanting a stent in the heart improved chest pain and exercise capacity:

  • More than a third who received a stent in the second trial were free of angina symptoms at the end of the trial 
  • These patients were three times more likely to have no angina at the end of the study compared to patients who received the placebo procedure

Participants and research teams were unaware if they had received a stent or placebo.

Dr Rasha Al-Lamee, NIHR Imperial BRC Cardiovascular Theme Co-Lead, who led the trial at Imperial College London and is also an interventional cardiologist at Imperial College Healthcare NHS Trust said: 

“The reality of clinical practice tells us that trying multiple chest pain medications is not realistic for patients who are experiencing uncomfortable angina symptoms. In the future, patients and medical teams have a choice of two pathways. For chest pain relief: anti-anginal chest pain medication or implanting a stent. All patients will need to continue medications that reduce their risk of future events such as heart attacks and death.

“The key finding from looking at our two trials together is that the first treatment offered seems to have the maximum effect. Stents are not risk or cost-free but their use as an upfront procedure can now be considered evidence-based and potentially effective for some patients.

“The trials suggest the American and European guidelines for stable coronary artery disease may require updating to offer more flexibility for patients and clinicians to decide which treatment is most appropriate. Our study suggests that by restricting stenting to patients with inadequate response to chest pain medications, we may inadvertently be selecting the group of patients with the least to gain.”

The research was partially funded by the NIHR, including the NIHR Imperial BRC Cardiovascular Theme Co-Lead Dr Al-Lamee. 

The results were published in the New England Journal of Medicine.

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