Diseases of the Heart Valves
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Aggressive Therapy for Older Hearts
There's no question coronary artery bypass grafting and angioplasty
can relieve the pain of angina, prevent heart attacks, and add years
to the lives of people with blocked coronary arteries. But most studies
have excluded people over age 70, so the benefits of aggressive therapy
is less clear in the older patient.
Two studies from Switzerland and Canada provide good news for older people
who may need bypass surgery or angioplasty. Swiss researchers compared
the effects of medical therapy and invasive therapy among more than 300
men and women with angina, all of whom were age 75 or over. They reported
the results in the journal Lancet. After six months, the frequency
and severity of chest pain had lessened and the quality of life had improved
in both groups. But the improvements were substantially greater, and
the heart attack rate substantially lower, among those who had undergone
bypass surgery or angioplasty.
The Canadian study, which appeared in the Canadian Medical Association
Journal, compared the effects of bypass surgery on patients in their
80s and those in their 70s. The investigators found it as safe and effective
for octogenarians as it was for septuagenarians and reported that it
cost about the same in either group.
Neither of these studies provides blanket assurance that an invasive
procedure like bypass surgery or angioplasty is right for every older
person with blocked coronary arteries. Older candidates for bypass surgery
or angioplasty may want to focus on quality-of-life issues. Recovery,
for example, may be a completely different experience for older people.
December 2001 Update
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Update on Fen-Phen and Heart-Valve Problems
Two recent studies are adding to the data concerning fen-phen and heart-valve
problems. These studies should offer some reassurance to patients who
took this combination of weight-loss drugs.
Researchers from Harvard Medical School evaluated echocardiograms performed
on 226 people who took fen-phen as part of a long-term study from September
1994 to September 1997. Shortly after the manufacturers voluntary
withdrawal of fen-phen, the medications were stopped and the patients
underwent testing to determine if any heart-valve problems had developed.
The echocardiograms showed that not one patient had severe valvular disease.
Mild leaking of the aortic valve was detected in 12 patients, and three
patients exhibited moderate aortic-valve leaking a total of 15
(6.6%) patients. Three subjects (1.3%) had moderate leaking of the mitral
valve. To compare the rate of heart-valve problems in these patients
to the rate one might expect to see in the general population, investigators
turned to data collected as part of the Framingham Heart Study (the long-term
epidemiological study being conducted in a Boston suburb). They found
nearly the same rates of aortic- and mitral-valve leaking in the Framingham
volunteers as in the diet-drug study participants.
A second study published in the November 23, 1999, issue of the American
Heart Association journal, Circulation, suggests that heart-valve
abnormalities in individuals who took dexfenfluramine (Redux) may dissipate.
Although study findings did link the drug to mild aortic-valve disease
and moderate mitral-valve problems, it also noted that valve problems
might eventually go away after drug use is stopped.
Using echocardiograms to spot heart-valve abnormalities, investigators
evaluated 223 patients who had taken dexfenfluramine for an average of
seven months. The tests were performed an average of 8.5 months after
the participants stopped taking the drug. None of the former dexfenfluramine
users was found to have severe mitral valve disease or moderate (or worse)
aortic-valve disease, but 7.6% had either mild aortic-valve disease or
moderate mitral-valve problems. People who had stopped treatment less
than eight months before the echocardiogram were twice as likely to have
valve problems than those who had been off dexfenfluramine for longer,
suggesting the problem regresses.
Could it be that these diet pills are safe after all? An editorial in
the Journal of the American College of Cardiology accompanied
publication of the Harvard study and asked whether there was adequate
proof of any increase in risk from fen-phen. No one is ready to go so
far as to suggest that these drugs should return to the market, but a
reasonable conclusion at this point is that there is an increased risk
of heart-valve problems, though the risk is probably quite small.
Regardless of the relative risks and merits of fen-phen and of
diet drugs in general weight loss remains a problem that cannot
be solved by any "magic bullet." Medications may help a little
in some patients, and surgical solutions might be considered for severely
overweight individuals. However, for most of us, regular exercise and
careful attention to how many calories we eat remain the best strategies
for successful and lasting weight loss.
Journal of the American College of Cardiology, Vol. 34, No. 4,
Circulation, Vol. 100, No. 21, pp. 216167.
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