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Shouldn’t You Try Medication Before Angioplasty?
 

People with chest pain are likely candidates of heart attack because they might have coronary artery disease (CAD). Being the leading cause of death for both men and women in the United States, CAD is a condition in which heart arteries are blocked or hardened.

In general, there are 3 ways to treat patients with CAD. If the disease is steady, doctors should first start with medications. Only after medications fail, balloon angioplasty and stenting should then be carried out. However, if the patients have multiple areas of coronary artery narrowing or blockage, doctors would ask the patients to undergo coronary artery bypass graft surgery (CABG).

A study by researchers from New York-Presbyterian Hospital/Weill Cornell Medical Center and other institutions found that the results of COURAGE trial that was published in 2007, did not change the way doctor treat millions of heart patients with CAD. In fact, many doctors still did not first try medicines that sometimes eliminate the need for costly and invasive procedures.

Being the most definitive randomized trial, COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) compared the effectiveness of OMT (Optimal medical therapy) versus OMT plus angioplasty in patients with stable CAD. The trial reported that intensive drug treatment in non-emergency patients with chest pain worked as well as angioplasty in preventing heart attack, improving survival and relieving discomfort in the long run.

OMT was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, beta-blocker, and statin), which are available as generics and cost much less than angioplasties.

The followed-up study evaluated data on nearly 500,000 American patients with stable CAD undergoing angioplasty in the National Cardiovascular Data Registry between September 1, 2005 and June 30, 2009. Two-thirds of these patients had chest pain and all eventually had artery-opening stents during an angioplasty. The findings were published on May 11, 2011 in the Journal of the American Medical Association (JAMA).

Researchers analyzed and compared use of OMT, both before angioplasty and at the time of discharge, before and after the publication of the COURAGE trial. It was found that among patients with stable CAD undergoing angioplasty, less than 50 percent were receiving OMT before angioplasty and approximately two-thirds were receiving OMT at discharge following angioplasty, with relatively little change in these practice patterns after publication of the COURAGE trial.

In the United States, about 1 million angioplasties are done or about $10 billion are spent each year. Nearly half of these patients had stable heart disease. It is estimated that more than $2 billion could be saved if treatment by medications were given first, and followed by angioplasties only if medications did not work.

So, why do doctors and patients still opt for the more expensive angioplasty?

From the doctors’ perspective, if they do not perform angioplasties and patients on drug treatment have heart attacks or die, they might be sued.

On the other hand, drug treatment is considered to be too time-consuming and labor intensive. Most patients just do not like to take medicines; instead they prefer to have a stent. Meanwhile, people often regard angioplasties as a high-tech approach. It is fairly common for patients underwent angioplasty to embrace their doctors afterward and express their gratitude for saving their life. Some doctors complain that patients never show appreciation if medication approach was adopted.

The new findings did not seem to surprise the researchers from Buffalo General Hospital, who conducted the COURAGE trial, because they felt that doctors would need some time to change their practice. It was reported that the American Heart Association (AHA) had decided to include the recommendations made by COURAGE trial in new treatment guidelines. Hopefully, this would influence more doctors to use the medication approach first.

Whether you like it or not, all heart disease patients should exercise everyday, keep a healthy weight, avoid smoking and stress and most importantly, they should take all the medicines as prescribed by their doctors.

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