An article in Milwaukee Journal-Sentinel points out less intervention is possible with drug treatment.
DR DAVIS COMMENTS: No surprise to those of us following the Track Your Plaque program.
Imagine if the study had gone beyond beta blockers, aspirin, and blood pressure management, and added fish oiil, vitamin D, eliminated wheat when appropriate, and corrected all hidden sources of plaque growth, among other strategies.
It would have been a hands down win for us. Proving it on a large scale, of course, is the hard part.
I am impressed that such a study got funded, given the clear-cut loss of revenues that will result. The fact that it came from the Veterans Administration tells us why. They have been on a cost-cutting spree out of budgetary necessity. However, I believe it is a simple extrapolation to believe that even standard medical therapy offers little benefit, at least from a symptom standpoint, to stenting.
The difficulty in employing this strategy in real life beyond the profitability of procedures is the fear of litigation. Symptomatic patient, abnormal stress test, managed "medically," dies of heart attack. Family now sues for failure to treat. Even if we know it was right, the damage is done. Such is the reality.
Nonetheless, bits and pieces of data like this VA study bolster the arguments that we have been discussing all this time: Procedures are not necessarily the solution to heart disease.
Drugs treat heart pain nearly as well as stents, study says
By JOHN FAUBER
jfauber@journalsentinel.com
Posted: Aug. 13, 2008
Common heart drugs worked nearly as well in treating chest pain in patients with stable heart disease as a more invasive and expensive procedure known as stenting, according to a study, suggesting that many of the hundreds of thousands of such procedures done each year may be unnecessary as a first-line treatment.
Because the decision to implant a stent often is made during a diagnostic cardiac catheterization, doctors say patients should discuss what should be done prior to undergoing the diagnosis.
If the angiogram finds a stable blockage that can be managed with just medications, the patient and doctor should agree on that course beforehand, said Robert Ninneman, chief of cardiology at Aurora St. Luke's Medical Center in Milwaukee.
Those who got stents and drug therapy had only a small additional benefit in pain relief and that disappeared within two to three years, compared with those who got drug therapy alone.
The finding, which was published Thursday in the New England Journal of Medicine, is the latest piece of research to question the need for the large numbers of elective angioplasties to open blocked coronary arteries. It's estimated that several hundred thousand of the elective procedures are performed each year in the United States.
In March 2007, the same researchers found that drug therapy performed equally well in preventing heart attacks and deaths in the same group of 2,287 patients.
The patients in the study were treated at hospitals in the U.S. and Canada for stable coronary disease with chest pain, known as angina, and a blockage of at least 70% in an artery.
The two phases of the study and other research now suggest that propping open the artery with angioplasty and placing a stent is not always called for, doctors said.
"There was a belief that a blockage had to be opened," said lead author William Weintraub, head of cardiology at Christiana Care Health System in Newark, Del., and a professor of medicine at Thomas Jefferson University in Philadelphia. "There are still doctors who believe that."
The study shows that many patients do well with drug therapy alone, Weintraub said.
"We know that's a safe approach," he said.
Unnecessary procedures
In 2006, a separate group of researchers found that as many as 50,000 angioplasties performed each year on heart attack patients days after they get to the hospital were unnecessary and may be harmful, although angioplasty performed up to 24 hours after heart attack symptoms begin is a proven lifesaver.
In the new study, each group of patients got optimal drug therapy, which included aggressive treatment with medications to lower cholesterol and blood pressure, blood thinners such as aspirin, and angina relief drugs such as nitroglycerin. In addition, about half the patients also underwent angioplasty with the placement of bare-metal stents.
Three months after the start of the trial, both groups had substantially improved pain relief.
Initially, those who underwent angioplasty had modestly better pain relief, but by three years there was no difference between the two groups. However, about one-third of those treated only with drugs eventually elected to undergo angioplasty and stenting.
"There is no doubt in my mind that stents are overused," said Robert Ninneman, chief of cardiology at Aurora St. Luke's Medical Center in Milwaukee.
Part of the problem lies with doctors, including family practice physicians and other doctors who refer patients with heart disease to cardiologists, he said. Often those doctors expect the problem to be fixed quickly with a stent because they may not want to spend a lot of time trying to adjust medicines taken by their patients and then persuading them to stay on the drugs, he said.
Interventional cardiologists, who perform angioplasty and put in stents, also contribute to the overuse of stents, he said.
Many like seeing their patients feel better right away, he said. And, he added, "There's a financial incentive for the interventional cardiologist to fix these things."
The average charge for an angioplasty procedure in 2004 was $44,110, according to the American Heart Association.
Patients also contribute to the overuse of stents by insisting on getting the devices instead of taking a handful of pills every day, Ninneman said.
"I spend a lot more time talking them out of stents," he said. "People want things fixed, and they hate medicine."
Ninneman said he hoped that the study will change the practice of doctors, but that likely will be a slow process.
Doctors pointed out that the study looked only at people with stable coronary disease, a group of several hundred thousand people who make up about one-third of all people who undergo angioplasty and stenting each year.
They noted that in situations such as when a person is having a heart attack or suffering from acute coronary disease, angioplasty and stents can be lifesavers.
Also, the study found that even among patients with stable heart disease, those with the more severe angina got greater benefit from angioplasty and drugs than from drug therapy alone.
But overall, 17 patients would have to be treated with angioplasty and drugs for one person to get a significantly greater amount of angina relief than was provided by drug therapy alone, the study found.
For every 1,000 people who were treated with angioplasty without first trying drug-only therapy, two would die during the procedure; 28 would have a heart attack at the time of the procedure; 60 to 90 would have an incremental pain benefit that would disappear with time; and 800 or more "would see neither harm nor benefit," according to an editorial that accompanied the study.
However, David Marks, director of the cardiac catheterization lab at Froedtert Hospital, noted that one-third of those in the study who initially were assigned to just drug therapy eventually elected to get a stent, suggesting that medication does not always work to control pain.
"They are both good strategies, but stenting offers more rapid and dramatic pain relief in some patients," said Marks, an associate professor of medicine at the Medical College of Wisconsin.
Still, drug therapy now has proven to be effective and it should be the first approach, said Eric Peterson, an associate professor of medicine at Duke University School of Medicine.
"A strategy of up-front angioplasty is not warranted," said Peterson, who also wrote an editorial that accompanied the study.
The study was funded by the U.S. Department of Veterans Affairs, the Canadian Institutes of Health Research and grants from several drug companies. Peterson and several of the study's authors have received consulting fees from companies that make heart medications. jsonline.com |
