MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Acupuncture is effective in alleviating angina when combined with traditional antianginal treatment, according to a study published today in JAMA Internal Medicine. Researchers conducted a 20-week randomized clinical trial at 5 clinical centres in China. Patients with chronic, stable angina (a serious symptom caused by coronary heart disease) were randomly assigned to 4 groups:

  1. acupuncture on acupoints in the disease-affected meridian,
  2. acupuncture on a non-affected meridian,
  3. sham acupuncture,
  4. waitlist group that did not receive acupuncture.

All participants also received recommended antianginal medications. Acupuncture was given three times each week for 4 weeks. Patients were asked to keep a diary to record angina attacks. 398 patients were included in the intention-to-treat analysis. Greater reductions in angina attacks occurred in those who received acupuncture at acupoints in the disease-affected meridian compared with those in the nonaffected meridian group, the sham acupuncture group and the wait list group.

“Acupuncture was safely administered in patients with mild to moderate angina”, Zhao et al wrote. “Compared with the [control] groups, adjunctive acupuncture showed superior benefits … Acupuncture should be considered as one option for adjunctive treatment in alleviating angina.”

This study is well-written and looks good – almost too good to be true!

Let me explain: during the last 25 years, I must have studied several thousand clinical trials of SCAM, and I think that, in the course of this work, I have developed a fine sense for detecting trials that are odd or suspect. While reading the above RCT, my alarm-bells were ringing loud and clear.

The authors claim they have no conflicts of interest. This may well be true as far as financial conflicts of interest are concerned, but I have long argued that, in SCAM, ideological conflicts are much more powerful than financial ones. If we look at some of the authors’ affiliations, we get a glimpse of this possibility:

  • Acupuncture and Tuina School, Chengdu University o fTraditional Chinese Medicine, Chengdu, Sichuan, China
  • Department of Acupuncture, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
  • Acupuncture and Tuina School, Hunan University of  Traditional Chinese Medicine, Changsha, Hunan, China
  • Acupuncture and Tuina School, Guiyang University of Traditional Chinese Medicine, Guiyang, Guizhou, China
  • Acupuncture and Tuina School, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
  • Acupuncture and Tuina School, Yunnan Provincial Hospital of Traditional Chinese Medicine, Kunming, Yunnan, China

I have reported repeatedly that several independent analyses have shown that as good as no TCM studies from China ever report negative results. I have also reported that data falsification is said to be rife in China.

I am aware, of course, that these arguments are hardly evidence-based and therefore amount to mere suspicions. So, let me also mention a few factual points about the new trial:

  • The study was concluded 4 years ago; why is it published only now?
  • The primary outcome measure was entirely subjective; an objective endpoint would have been valuable.
  • Patient blinding was not checked but would have been important.
  • The discussion is devoid of any critical input; this is perhaps best seen when looking at the reference list. The authors cite none of the many critical analyses of acupuncture.
  • The authors did actually not use normal acupuncture but electroacupuncture. One would have liked to see a discussion of effects of the electrical current versus those of acupuncture.
  • The therapists were not blinded (when using electroacupuncture, this would have been achievable). Therefore, one explanation for the outcome is lies in the verbal/non-verbal communication between therapists and patients.
  • Acupuncture was used as an add-on therapy, and it is conceivable that patients in the acupuncture group were more motivated to take their prescribed medications.
  • The costs for 12 sessions of acupuncture would have been much higher (in the UK) than those for an additional medication.
  • The practicality of consulting an acupuncturist three times a week need to be addressed.
  • The long-term effects of acupuncture on angina pectoris (which is a long-term condition) are unknown.

Coming back to my initial point about the reliability of the data, I feel that it is important to not translate these findings into clinical routine without independent replications by researchers from outside China who are not promoters of acupuncture. Until such data are available, I believe that acupuncture should NOT be considered as one option for adjunctive treatment in alleviating angina.

14 Responses to Acupuncture for angina pectoris! Too good to be true?

  • JAMA? Really? I took a quick look at the articles on their website. Most of them seem to be reality based. How the hell did this get by the reviewers?

  • Just came across this….

    https://medicalxpress.com/news/2019-07-therapy-ageing.html

    I’m not sure what to think of it. Any comments?

  • JAMA is my daily source of junk science. It has failed to maintain a reputation as a credible journal. Nowadays, much of its content and editorial also has a political spin or agenda.

  • Also the people in the sham group would have realized they are in the sham when they didn’t get the “Deqi”sensation. From the paper, the Deqi sensation involves “sensation of soreness, numbness, distention, or radiating, which is considered to indicate effective needling”. Now how on earth are they going to make this an effective sham, especially when people who already had acupuncture before. As you said, they should have reported how many in the sham group were actually blind.

  • Randomized trials published in some Chinese journals lacked an adequate description of randomization, this cannot be generalized to Chinese research published in high impact western journals such as JAMA. This study replicated the results of other studies conducted outside China and published in Western journals.

    • please provide link so that one can assess the rigour of these studies.

    • @Bernardo Coutinho

      “Randomized trials published in some Chinese journals lacked an adequate description of randomization, this cannot be generalized to Chinese research published in high impact western journals such as JAMA.”

      There are many incentives for scientific dishonesty. At least one of them has no national or geographical limitations: money. The Chinese Government has, since the late 1990s, offered the incentive of cash payments for its scientists who publish in top Western Journals. The sum paid increases with the journal’s prestige.

      Read this article for details.

      BTW, this system may also provide an answer to Edzard’s question about publication delay.

    • You wrote, “This study replicated the results of other studies conducted outside China and published in Western journals.”

      The authors specifically contradict that in the discussion section. “The prior 2 studies found no significant difference between true acupuncture and SA [Sham Acupuncture] in improving the rate of angina attacks.14,20”

      The authors do refer to their results producing results similar to those of a systematic review of studies of acupuncture NOT compared with sham acupuncture, which strongly suggests that this study did not do an adequate job of blinding participants. “Our findings are consistent with those of a previous systematic review22 that examined the effectiveness of combined acupuncture and antianginal treatment vs antianginal medications alone.”

      This study only replicates acupuncture plus conventional treatment vs. only conventional treatment studies, which are really only studies of placebo effects.

      This study does NOT replicate the previous acupuncture vs. sham acupuncture studies.

      .

  • There were some semi-objective endpoints: use of rescue medicine and 6 minute walk test. If I’m interpreting the table correctly, they report no statistical difference for the most objective measure (rescue meds) and only a pvalue of 0.03 for the walk test which would not be significant given the large number of comparisons they did.

Leave a Reply to Kathryn Cancel reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

If you want to be able to edit your comment for five minutes after you first submit it, you will need to tick the box: “Save my name, email, and website in this browser for the next time I comment.”
Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted but you must tick the box: “Save my name, email, and website in this browser for the next time I comment.”

The most recent comments from all posts can be seen here.

Archives
Categories