Can Exercise Be Better than a Stent for Stable Angina?

Aerobic exercise is usually prescribed for heart patients after specialist treatment, but maybe it could be used instead of angioplasty.  That’s the message coming from Dr Rainer Hambrecht at the European Congress of Cardiology 2009 Congress.

Stable angina is the type of heart-related pain that occurs at times of stress or activity.  It usually gets worse over a few minutes and then goes away with rest, or can be cut short with medication (e.g. nitroglycerin pills or spray).  Angioplasty and stent placement (also called percutaneous coronary intervention, or PCI) offers a cure for stable angina.  It involves inserting a catheter through an artery in either the arm or leg and advancing it into a coronary artery that has become too narrow, due to coronary atherosclerosis; a small balloon dilates the artery and the stent holds the dilated artery wide open.  Relief from angina is almost instantaneous. 

Dr Hambrecht conducted a study in over 100 stable angina patients, who were randomly allocated to have angioplasty with stent placement, or exercise training, which was supervised for the first 2 weeks.  The results of this trial were encouraging, and he embarked on a larger study at 4 hospitals in Germany, Austria, Switzerland, and Rumania.  Recruitment in this study was problematic; only 100 of the expected 400 patients were actually enrolled.  But when the results of this study were pooled with the first study, for a total of 202 patients, with a 2-year follow-up, the findings were clear-cut.  There were 21 ‘events’ (i.e. heart attack, unstable angina, or sudden cardiac death) in the exercise group, compared with 32 such events in the PCI group.

One should note that the efforts expended on exercise were monitored; after the first two weeks, patients were given a bicycle at home to use every day, and were asked to attend a supervised program once or twice a week.  The bikes had a sensor that counted the amount and duration of exercise.  The difficulties in recruiting were almost entirely for subjects willing to be randomized to an exercise group.  With PCI and a stent, the subjects were free of pain almost immediately, whereas those undertaking cardiac training had to work a lot, for several months, to reduce the angina threshold. Nevertheless, apart from the results just quoted, there is another important advantage of exercise training over a PCI.  Exercise improves the function of the cells lining the blood vessels (the endothelium) and slows disease progression, whereas PCI plus a stent merely addresses the problem at one, or several, points in the coronary artery system.  Maybe a little continued pain is worth it?