Pills as good as stents for stable heart patients: analysis
Gerald Hurowitz, M.D.·Published 29 February 2012·7 min read
Key points
Treating stable heart patients with a handful of pills works just as well as propping open blocked heart arteries with a stent, U.S. researchers said on Monday, adding to evidence that less-invasive, less-costly drug treatment works as well as implanting a medical device in such patients.
Doctors can help people with blocked coronary arteries in a number of different ways, depending upon the severity of symptoms experienced as a result.
"The meta-analysis published in Archives of Internal Medicine uses old data, from 1995 to 2005, which offer little, if any, new information to guide clinical care," Dr.
Coronary artery disease or blocked arteries is a condition diagnosed with the help of a thorough physical examination, electrocardiogram, coronary angiography, a chest x-ray and prescribed blood tests.
Treating stable heart patients with a handful of pills works just as well as propping open blocked heart arteries with a stent, U.S. researchers said on Monday, adding to evidence that less-invasive, less-costly drug treatment works as well as implanting a medical device in such patients.
Stents, made by companies such as Boston Scientific Corp, Abbott Laboratories and Medtronic Inc, are still the preferred treatment for opening up blocked heart arteries in patients rushed to the hospital with an acute heart attack.
But several studies have shown the heart devices are no better than drugs in patients with stable heart disease, in which heart arteries have narrowed and may be causing chest pain.
The latest analysis by Dr. Kathleen Stergiopoulous and Dr. David Brown of Stony Brook University Medical Center in New York, published in the Archives of Internal Medicine, attempts to knock down lingering arguments that earlier results were based on outdated technology.
Older analyses had included data from trials comparing drug treatments with balloon angioplasty, in which a balloon-tipped catheter is inserted and the balloon is inflated to open the narrowed passage.
For the latest so-called meta-analysis, the team pooled data only from newer studies that compared drug treatments with stents - a wire-mesh tube used to prop open the artery and prevent it from reclosing.
"The question was is there any benefit to stenting the blockages in these patients as an initial therapy procedure over treating them with optimal medical therapy and referring them to get a stent if necessary," Brown said in a telephone interview.
QuestionHow can doctors help blocked coronary arteries?
Answer
Doctors can help people with blocked coronary arteries in a number of different ways, depending upon the severity of symptoms experienced as a result.
The majority of people who experience pain owing to a lack of oxygen to the heart muscle (angina) have their symptoms controlled with oral medication and never need to be considered for a more invasive form of treatment.
Those who can be shown to be more severely affected, in that the blockages present are reducing the blood supply to the heart in such a way as to make oral treatment ineffective, may then be considered for other treatments such as angioplasty or coronary artery bypass grafting (CABG).
Angio = blood vessel; plasty = surgical shaping or alteration of. In this procedure a catheter with an inflatable tube is inserted into a blocked or partially blocked coronary artery in order to relieve the blockage.
A CABG procedure utilises a section of the patient's leg vein to bypass a partial or complete blockage in the coronary artery system.
Written and revised by
Gerald Hurowitz, M.D.
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Occasionally an artery such as the internal mammary artery may also be incorporated into the operation to maximise blood flow to the heart.
The analysis included results on more than 7,200 patients enrolled in eight studies between 1997 and 2005 comparing stents with medical therapy in stable heart patients with narrowed sections in their heart arteries.
"The result showed quite clearly there was no benefit of stenting as far as reducing death, heart attack, repeat procedures and even reducing symptomatic angina (chest pain)," Brown said.
He added that his analysis was the first to include only studies that used stents, and the results offered the most up-to-date comparison of the benefits of stenting procedures with modern medical therapy, which includes aspirin, a variety of blood pressure medicines such as beta-blockers, ACE-inhibitors or angiotensin receptor blockers and cholesterol-lowering statins.
'MISSES THE MARK'
Still, some doctors were not satisfied.
"The meta-analysis published in Archives of Internal Medicine uses old data, from 1995 to 2005, which offer little, if any, new information to guide clinical care," Dr. Theodore Bass, vice president of the Society for Cardiovascular Angiography and Interventions, a group of heart doctors that specialize in stenting procedures.
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Bass said in an email that the study "misses the mark" on the quality-of-life concerns for patients and that stenting procedures helped relieve chest pain, or angina, in stable patients.
Dr. William Boden of the Samuel S. Stratton VA Medical Center in Albany, New York, who wrote a commentary in the journal, said relieving angina appeared to be the "last remaining sacred cow" for doctors who argue in favor of stents over drugs.
Boden is the lead author of a large study called COURAGE published in 2007 in the New England Journal of Medicine that was one of the first to challenge the value of stents and angioplasty over drug treatment.
Treatment for Blocked Arteries
Coronary artery disease or blocked arteries is a condition diagnosed with the help of a thorough physical examination, electrocardiogram, coronary angiography, a chest x-ray and prescribed blood tests. The blood tests are usually conducted to analyze and evaluate cholesterol level, diabetes and the thyroid hormone. The medical history of the family also plays a key role in determining the presence of this cardiac disorder in the individual. The treatment of blocked arteries involves, first and foremost, educating the patient on the life-threatening condition and explaining the outcome of the disease. Further damage can be prevented with the help of:
- Lifestyle changes like cessation of the smoking habit, a dedicated diet plan and very importantly, regular exercise. - Medication prescribed by the doctor, which commonly includes beta-blockers, calcium-channel blockers and nitrates. Thrombolytic drugs are also prescribed to dissolve blood clots (if any), by increasing the blood plasmin level. - Blood volume and pressure are lessened with the help of diuretics such as Esidrix and Diuril. Medication for blocked arteries also includes ACE inhibitors, angiotensin-2, vasodilators and statins. - Surgical procedures such as coronary artery bypass and angioplasty or percutaneous transluminal coronary angioplasty, may be performed, in case the blockage is intense. In coronary artery bypass, the chest area is opened and a vein from the thigh or lower leg is used to enable the passage of blood around the blocked region. - Coronary angioplasty is a procedure where a hollow tube or guide catheter is inserted into the artery. A catheter balloon is inflated within the artery to widen the walls. A stent is then placed in the artery to prevent it from narrowing again, thus restoring normal blood flow.
In that study, patients with chest pain did get slightly more pain relief with stenting, but those benefits only lasted one to three years. "They are not durable," he said.
More recent studies could not show stents were any better than drugs at relieving angina, he contended.
Boden and Brown attribute the changes to improvements in medications, and given that most of them are generic, getting more doctors to choose drugs first could save a lot in health costs.
"In the context of controlling rising health care costs in the United States, this study suggests that up to 76 percent of patients with stable coronary artery disease could avoid percutaneous coronary intervention (such as stenting) altogether if treated with optimal medical therapy," Brown and Stergiopoulous wrote.
But fewer than half of Americans with stable coronary artery disease who get a stent have been treated with drugs first, Dr. Rita Redberg, editor of the Archives of Internal Medicine, said in an editorial.
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She said more than 1 million stents were implanted each year to treat coronary artery disease in the hopes that stents would work better than drugs, despite ample evidence to the contrary.
Brown said part of the reason doctors ignored those studies was that there was a big financial incentive to use stents versus drugs.
How are clogged arteries or arterial plaque treated?
There are a variety of prevention and treatment options for clogged arteries. What your doctor prescribes to reduce arterial plaque and prevent clogged arteries will depend on the severity of your condition and your medical history. Your doctor may prescribe one or more of the following:
1. Lifestyle changes. A healthy lifestyle is essential for the management of arterial plaque and treatment of clogged arteries. This includes:
- eating a diet low in saturated fats and cholesterol and rich in fruits and vegetables - maintaining a healthy body weight - not smoking - exercising regularly - managing stress levels
2. Surgical procedures. In some instances, surgery may be necessary to treat clogged arteries and prevent additional arterial plaque accumulation. Surgery may include:
Stent placement. A metal tube called a stent, which may contain medication, can be placed in an artery to maintain adequate blood flow. Bypass surgery. In this operation, arteries from other parts of the body are moved to bypass clogged arteries and help oxygen-rich blood reach its target destination. Balloon angioplasty. This procedure helps open clogged arteries that have become partially or fully blocked.
3. Medications. A number of medications exist that may help control some of the factors that contribute to the accumulation of arterial plaque. These include:
- cholesterol-lowering drugs - blood pressure-lowering drugs - aspirin and other blood-thinning drugs, which reduce the likelihood of dangerous blood clot formation
"If I put a stent in you, I submit a bill for my fee, which could be $1,000 to $2,000. The hospital submits another bill for using the hospital, the stent, the equipment and nursing time," he said. The whole thing could add up to $20,000 or $30,000.
Brown therefore doubts the study will sway too many doctors, but said it may influence insurance companies.
"A few practitioners might change their behavior, but third-party payers will be influenced by it and they will start by making stricter criteria for reimbursing these procedures," he said.
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