MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Stable angina is a symptom of coronary heart disease which, in turn, is amongst the most frequent causes of death in developed countries. It is an alarm bell to any responsible clinician and requires causal, often life-saving treatments of which we today have several options. The last thing a patient needs in this condition is ACUPUNCTURE, I would say.

Yet acupuncture is precisely the therapy such patients might be tempted to employ.

Why?

Because irresponsible or criminally naïve acupuncturists advertise it!

Take this website, for instance; it informs us that a meta-analysis of eight clinical trials conducted between 2000 and 2014 demonstrates the efficacy of acupuncture for the treatment of stable angina. In all eight clinical trials, patients treated with acupuncture experienced a greater rate of angina relief than those in the control group treated with conventional drug therapies (90.1% vs 75.7%)….

I imagine that this sounds very convincing to patients and I fear that many might opt for acupuncture instead of potentially invasive/unpleasant but life-saving intervention. The original meta-analysis to which the above promotion referred to is equally optimistic. Here is its abstract:

Angina pectoris is a common symptom imperiling patients’ life quality. The aim of this study is to evaluate the efficacy and safety of acupuncture for stable angina pectoris. Clinical randomized-controlled trials (RCTs) comparing the efficacy of acupuncture to conventional drugs in patients with stable angina pectoris were searched using the following database of PubMed, Medline, Wanfang and CNKI. Overall odds ratio (ORs) and weighted mean difference (MD) with their 95% confidence intervals (CI) were calculated by using fixed- or random-effect models depending on the heterogeneity of the included trials. Total 8 RCTs, including 640 angina pectoris cases with 372 patients received acupuncture therapy and 268 patients received conventional drugs, were included. Overall, our result showed that acupuncture significantly increased the clinical curative effects in the relief of angina symptoms (OR=2.89, 95% CI=1.87-4.47, P<0.00001) and improved the electrocardiography (OR=1.83, 95% CI=1.23-2.71, P=0.003), indicating that acupuncture therapy was superior to conventional drugs. Although there was no significant difference in overall effective rate relating reduction of nitroglycerin between two groups (OR=2.13, 95% CI=0.90-5.07, P=0.09), a significant reduction on nitroglycerin consumption in acupuncture group was found (MD=-0.44, 95% CI=-0.64, -0.24, P<0.0001). Furthermore, the time to onset of angina relief was longer for acupuncture therapy than for traditional medicines (MD=2.44, 95% CI=1.64-3.24, P<0.00001, min). No adverse effects associated with acupuncture therapy were found. Acupuncture may be an effective therapy for stable angina pectoris. More clinical trials are needed to systematically assess the role of acupuncture in angina pectoris.

In the discussion section of the full paper, the authors explain that their analysis has several weaknesses:

Several limitations were presented in this meta-analysis. Firstly, conventional drugs in control group were different, this may bring some deviation. Secondly, for outcome of the time to onset of angina relief with acupuncture, only one trial included. Thirdly, the result of some outcomes presented in different expression method such as nitroglycerin consumption. Fourthly, acupuncture combined with traditional medicines or other factors may play a role in angina pectoris.

However, this does not deter them to conclude on a positive note:

In conclusion, we found that acupuncture therapy was superior to the conventional drugs in increasing the clinical curative effects of angina relief, improving the electrocardiography, and reducing the nitroglycerin consumption, indicating that acupuncture therapy may be effective and safe for treating stable angina pectoris. However, further clinical trials are needed to systematically and comprehensively evaluate acupuncture therapy in angina pectoris.

So, why do I find this irresponsibly and dangerously misleading?

Here a just a few reasons why this meta-analysis should not be trusted:

  • There was no systematic attempt to evaluate the methodological rigor of the primary studies; any meta-analysis MUST include such an assessment, or else it is not worth the paper it was printed on.
  • The primary studies all look extremely weak; this means they are likely to be false-positive.
  • They often assessed not acupuncture alone but in combination with other treatments; consequently the findings cannot be attributed to acupuncture.
  • All the primary studies originate from China; we have seen previously (see here and here) that Chinese acupuncture trials deliver nothing but positive results which means that their results cannot be trusted: they are false-positive.

My conclusion: the authors, editors and reviewers responsible for this article should be ashamed; they committed or allowed scientific misconduct, mislead the public and endangered patients’ lives.

7 Responses to Acupuncture for stable angina pectoris… yes, if you aim at killing millions!

  • If this catches on, it’ll certainly reduce the prevalence of ischaemic heart disease

  • The authors’ discussion of drugs deals with physiological effects and how they can be of benefit but also potentially harmful. Discussion of the effects of acupuncture is in terms of “channels” and “qi”. Only benefits are found. Messing about with qi never produces harmful effects. The effects of drugs are scientifically meaningful; the effects of acupuncture are not. Thus, any benefits claimed for acupuncture defy scientific explanation.

    This fact renders claims of efficacy of acupuncture for angina beyond dubious. The trials which were included in the meta-analysis need to be scrupulously reviewed. Did those trials involve sham acupuncture controls? If not, we cannot assume that acupuncture is more effective than a placebo. Was randomising appropriate? Blinding was necessarily non-existent for practitioners and patients as regards allocation to drugs v acupuncture. Was self-selection at work? Had drugs already failed the patients involved? Were some disappointed not to have been allocated to the acupuncture group; and some delighted to have been given a new treatment?

    Could patient and practitioner bias account for the results?

    It appears that patients were receiving other traditional treatments as well as acupuncture. What exactly were those other treatments? Traditional Chinese “herbal” remedies contain all kinds of ingredients (chemistry) which could confound the trials.

    The paper lists a number of positive trials for acupuncture used as an adjunct with Chinese herbs; they too are meaningless unless appropriate controls were employed. My guess is they were not.

    The authors reference the out-of-date and contentious NIH Consensus Statement of 1997 supporting acupuncture. Much more and much better evidence presently exists, pointing unequivocally to acupuncture being just an elaborate placebo. Much more and just as poor evidence as that available in 1997 also now exists. A meta-analysis of a bunch of poor or even meaningless studies, is meaningless.

  • “Stable angina is a symptom of coronary heart disease which, in turn, is amongst the most frequent causes of death in developed countries. It is an alarm bell to any responsible clinician and requires causal, often life-saving treatments of which we today have several options.”

    There are few treatments for “stable” angina that probably offer prognostic benefit e.g. if angiography reveals a left-main stem disease. The majority of treatments, e.g. Nitrates, only offer symptomatic benefit. Even the NICE guidelines are titled ‘chest pain of recent onset’.

    And even when drugs are given to improve symptoms often they don’t work and something else needs to be tried. Sometimes nothing works and they need to go to a chronic pain clinic. Essentially they are comparing Acupuncture to something that doesn’t work well & doing it badly. I also think there is probably a big placebo effect, which I doubt they controlled for.

    I hope these needles aren’t going anywhere near the heart: pretty good way to cause acute pericardial tamponade I’d guess.

    • what about stents? or normalisation of risk factors?

      • Hi Prof,

        the vast majority of stents (in chronic disease) only improve symptoms and do not affect prognosis. It is different if very important lesion or a large area of ischemia, although in that case they would often be better with cardiac surgery. Stents are also inserted often before medications have been optimised, in-contrast to the practice in the research studies.

        Yes, sorry, I maybe minimised the benefits of treatments for risk factors, but these are only a few that can be treated and this does not include the majority of medication treatments. Much of the evidence for benefit is clearer in the short term in patients who have unstable disease and then is extrapolated into the treatment of long term stable disease. These medications would have been started when the chest pain was unstable and I was thinking, wrongly, of additional treatments. There is a separate set of research in patients who develop heart failure, the majority of which is secondary to coronary artery disease.

        In patients who have optimised medications, been to cardiac rehab and in whom the risks of surgery/intervention are greater than the benefits there aren’t any further prognostically beneficial treatments. I would hope it was this sub-population in whom the acupuncturists were restricting themselves. I suspect they are not even that responsible.

        I’d be much more concerned if acupuncturists wanted to treat unstable angina or heart failure.

        • Most acupuncturists wouldn’t know the difference between “heartburn” and “angina” anyway.

          • Nope, they should definitely stay away from diagnosing anything.

            I would also be concerned what they would do if stable angina became unstable: would they suggest GP/A&E or would they think themselves capable…

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