Better Long-Term Outcomes with Medications versus Angioplasty
There are some advantages to artery-opening angioplasty over medication treatment for people with heart disease, but those advantages disappear within three years, according to a report in the New England Journal of Medicine.
Angioplasty does offer a higher quality of life for months to a couple of years, says study leader Dr. William S. Weintraub, chief of cardiology at the Christiana Health Care System in Newark, Delaware.
In the COURAGE trial, the researchers tested angioplasty, with stent implants, against medication treatment for 2,287 people with stable coronary disease.
Earlier analysis found improved quality of life for those having the artery-opening procedure that is formally called percutaneous coronary intervention (PCI).
The new report found that by 36 months, there was no significant difference in health status between the two treatment groups.
"What one can say is that for people with chronic, stable coronary disease, PCI can be deferred," Dr. Weintraub says. "They can continue on medication aimed at their specific risk factors - hypertension, lipid disorders, diabetes - and should be encouraged to have a good lifestyle, with exercise, smoking cessation, and weight control."
Doctors Assess Needs
A decision to have PCI can depend on how an individual feels, says Dr. Weintraub.
"If people say, 'My pain is so bad I can't function,' that is one thing. If people say, 'I have angina, but I'm doing OK,' that's another," he says.
Angina is the chest pain that is a chief symptom of coronary disease.
Cost could be a factor in some decisions, notes Dr. Weintraub. PCI is more expensive than medication therapy, but the current report does not mention money.
However, a preliminary cost-benefit analysis presented by Dr. Weintraub last November found that "PCI adds about $10,000, without any significant gain in years of survival or quality of life."
The cost of one year of life added by PCI varies from $150,000 to $300,000, the analysis found.
The cost of PCI versus medication treatment must be considered "by society as a whole," he says. "But when a doctor talks to a patient, the doctor is an advocate for that patient."
An individual's health insurance status can matter, Dr. Weintraub acknowledges.
"Paying the cost out of pocket gives one a different point of view," he says.
The attitude of medical insurance providers does matter, says Dr. Eric D. Peterson, at the Duke Clinical Research Institute. Insurance companies now are quite willing to pay for PCI, and "until that category is changed, the effect of this study will be modest," he says.
Medical Therapy for Stable Heart Disease
The COURAGE results show that PCI should not be the treatment of choice for people with stable heart disease, says Dr. Peterson.
"We have justified angioplasty for years by saying it is of great benefit to patients," he says. "This study shows no survival benefit and shows that the benefit in regard to symptom relief is temporary. Medical therapy should be considered for all patients with stable angina, unless they have severe pain when diagnosed."
The fact that 21 percent of those in the COURAGE trial who started on medication treatment eventually had PCI shows that a decision on surgery can safely be delayed, he says.
The hazards as well as the benefits of PCI should be considered when a decision is made, notes Dr. Peterson.
Of 1,000 persons undergoing PCI, two will die, 28 will have heart attacks related to the procedure, 60 to 90 will have improved symptom relief, and 800 will have no noticeable benefit above that given by drug treatment, his editorial explains.
Always consult your physician for more information.
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