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Medication vs. stents for heart disease treatment

What’s the best way to “fix” a narrowed coronary artery? That question was the crux of a multimillion-dollar trial dubbed COURAGE, short for Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation. Its results, presented in the spring of 2007, stunned some doctors and seemed to shock the media, but we hope they won’t come as a surprise to readers: For people with stable coronary artery disease (clogged arteries nourishing the heart), artery-opening angioplasty was no better than medications and lifestyle changes at preventing future heart attacks or strokes, nor did it extend life.

The media tended to play up the COURAGE results, which were presented at the American College of Cardiology’s annual meeting in March, as a David slays Goliath story. But it wasn’t that at all.

Before going any further, it’s important to stress that this trial compared angioplasty and medical therapy only for stable angina (chest pain on exertion) or narrowed coronary arteries that don’t cause any symptoms. For a sudden blockage of a coronary artery, emergency artery-opening balloon angioplasty followed by the placement of a stent is the best remedy around.

Direct comparison

The COURAGE trial signed up 2,287 volunteers, all of whom had at least one coronary artery severely narrowed by cholesterol-filled plaque. They also had clear evidence of limited blood flow to part of the heart (ischemia), either chest pain or alarming signs on an electrocardiogram or stress test. Half were randomly assigned to angioplasty plus a stent with state-of-the-art follow-up care. The other half had optimal medical therapy — drugs to ease or prevent angina, to protect the heart and blood vessels, and in some cases to boost protective HDL. Exercise and healthful eating were also stressed.

After an average follow-up of four and a half years, the two groups were remarkably similar. Getting angioplasty and a stent to hold open a narrowed artery didn’t offer any extra protection against a heart attack, stroke, hospitalization for acute coronary syndrome (the umbrella for heart attack and unstable angina), or premature death.

The only big differences were in freedom from angina and the need for follow-up procedures. After one year, 66% of those who underwent angioplasty were free from angina, compared with 58% of those on medical therapy. By five years, though, there was no difference, with about 73% of both groups reporting no angina.

In follow-up procedures, about 20% of those who initially underwent angioplasty needed a repeat angioplasty or bypass surgery, while 31% of those who started on medical therapy eventually needed to have angioplasty or bypass surgery.

COURAGE results

In the COURAGE trial, angioplasty was no better than medical therapy for preventing later cardiovascular problems.

Outcome

Angioplasty plus stent

Medical therapy

Death or nonfatal heart attack

19.0%

18.5%

Death, nonfatal heart attack, or stroke

20.0%

19.5%

Heart attack

13.2%

12.3%

Subsequent angioplasty or bypass surgery

19.8%

30.6%

Stents for pain, not protection

The key lesson from COURAGE is that people with stable angina or a narrowed coronary artery have choices. These problems aren’t ticking time bombs that must be fixed right away, especially if you feel fine.

There are only two reasons for undergoing any treatment: to feel better or to live longer. If you aren’t having chest pain or other symptoms, angioplasty to open a narrowed artery can’t make you feel any better. And the results of COURAGE and earlier studies show it won’t help you live any longer.

Having one plaque big enough to limit blood flow usually means others are lurking nearby. Squash it against the wall of a coronary artery with a stent, and others will pop up elsewhere, like a game of arterial Whac-a-Mole. Fighting atherosclerosis means attacking the disease on all fronts: with exercise and healthful eating; medications that stabilize plaque, hinder blood clots from forming in the heart’s arteries, and prevent harmful changes in the shape of the heart; and efforts to control blood pressure and cholesterol.

Making choices

If you have chronic angina, it’s worth giving medical therapy the old college try. One of the findings from COURAGE that surprised even researchers was how effective medical therapy was at relieving angina and improving quality of life. You might be surprised at how well exercise, a better diet, and medications can make you feel. If, after six months to a year, your angina is still bothering you or keeping you from doing activities you enjoy, angio-plasty or bypass surgery are reasonable next steps.

June 2007 update

Diagnosis: Coronary Artery Disease

Most people fear heart disease — and with good reason: it’s the leading cause of death for both men and women. But something that people may not realize is that preventing this disease is often within their control. Most people who develop heart disease have one or more major risk factors that are within their power to change. These include lack of exercise, high blood pressure, and abnormal cholesterol levels. There are surefire ways to tackle these risk factors that you can include… Learn more »

Posted by: Dr.Health

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