Therapy found as useful as stents in treating pain of heart disease
New study results raise more questions about a “procedure first” strategy for treating patients with stable heart disease.
The researchers, including a Buffalo physician, found that aggressive medical therapy and such procedures as stenting both significantly improve the health and quality of life of patients.
Patients with chronic coronary artery disease found relief from chest pain, called angina, whether they were treated with stents and medical therapy, or with optimal medical therapy alone, according to the study publishedn the New England Journal of Medicine.
In the study, an initial strategy of stents added to medical therapy relieved angina and improved health to a greater extent than an initial strategy of optimal medical therapy alone, although the difference didn’t last more than two years.
A greater benefit from stents was observed in patients with more severe angina.
The conclusions come from analysis of data from a study released earlier this year known as COURAGE, or Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation.
The results challenge current medical practice for the treatment of heart disease by offering significant evidence that drug treatment in many patients works just as well to prevent heart attacks and death as do procedures to unclog arteries, according to William E. Boden, lead author of the first COURAGE study and senior author of the latest paper.
“COURAGE tells us that aggressive medical therapy has leveled the playing field,” said Boden, medical director of cardiovascular services at Kaleida Health and clinical chief of the University at Buffalo’s Division of Cardiovascular Medicine.
More than 1 million patients a year have narrowed or blocked arteries of the heart opened by stents. The COURAGE study strongly suggests the procedures may be overused and unnecessary for many non-emergency patients with chest pain caused by the blockages.
In assembling the quality-of-life data, COURAGE researchers assessed 2,287 trial participants at 50 hospitals in North America on such measures as angina frequency and overall quality of life.
The COURAGE findings are forcing a debate among doctors over the use of wire-mesh stents and other percutaneous coronary interventions to open blocked arteries, especially among patients with mild chest pain or no symptoms at all. This is especially so with the greater availability of more effective medications, in combination with diet and exercise, to reduce cholesterol levels, control blood pressure, prevent blood clots and prevent chest pain.
Boden and other advocates of medical therapy said studies like COURAGE should give physicians the confidence to offer patients nonsurgical alternatives. But in an editorial that accompanied the study, several physicians wrote that courage will be needed to change medical practices and policies so that managing medications is as valued as performing procedures.
Interventional cardiologists, the specialists who perform stenting and other heart procedures, strongly defend the procedures, which have been shown to be extremely effective with low rates of complications.
“The study doesn’t change anything. The conclusions are consistent with what we’ve known — percutaneous coronary interventions relieve symptoms and save lives,” said Dr. Bonnie Weiner, past president of the Society for Cardiovascular Angiography and Interventions.
Weiner, echoing other critics, said the study focused on patients who represent a minority of those with heart disease and excluded patients at higher risk of having heart attacks. She also said medical therapy advocates neglect to account for the strong desire among many patients with mild chest pain to obtain immediate symptom relief, and the inability of others to tolerate drugs well or stay on a regimen.
“This shouldn’t be an either-or issue. We should look at each patient individually. It should be medical therapy with or without (interventions),” said Weiner, a Worcester, Mass., interventional cardiologist.
