Cardiologists rush to angioplasty despite evidence for value of drugs

You can lead a cardiologist to water but, apparently, you cannot make him drink.

Despite the results of a recent major clinical trial that demonstrated conclusively that good medical therapy is just as effective as balloon angioplasty or coronary artery bypass surgery for treating stable coronary disease, fewer than half of cardiologists use such therapy before subjecting their patients to the much more expensive surgical intervention, researchers said this week.

Even after the interventions, which are known formally as percutaneous coronary intervention, or PCI, fully a third of the patients still do not receive optimal medical therapy, the researchers reported in the Journal of the American Medical Assn. “The fact that clinical practice has not significantly changed in regard to the treatment of PCI patients with better medical therapy is concerning,” said Dr. Barry Kaplan, a cardiologist at North Shore University Hospital in Manhasset, N.Y., who was not involved in the study.

The researchers are not talking about patients who have suffered a heart attack because of a blocked coronary artery. Rather, the studies involve those who have a partial blockage that impairs their ability to get around and carry out the normal activities of life. About 65% of balloon angioplasties are performed on such patients currently.

The 2007 study called COURAGE enrolled 2,287 patients with stable coronary artery disease. Half were given angioplasty plus optimal medical therapy and half were given only the medical therapy. Such therapy typically includes administration of statins to reduce cholesterol, beta-blockers, ACE inhibitors and diuretics to reduce blood pressure and aspirin or other blood thinners to prevent excessive clotting. Dr. William E. Boden of the University of Buffalo School of Medicine and his colleagues reported that patients in the two groups had the same number of heart attacks and strokes after treatment. The only difference was that patients receiving only medical therapy had more frequent chest pains, called angina. Those pains were manageable, however. The study was expected to make a big difference in how cardiologists treat patients with the disorder. Apparently it did not, however.

In a follow-up study, Dr. William B. Borden of the Weill Cornell Medical College in New York and his colleagues studied 467,211 patients who had received PCI between September 2005 and June 2009. All the patients were enrolled in the National Cardiovascular Data Registry of patients with stable coronary disease who underwent the procedures. About 37.1% of the patients underwent the procedure before the COURAGE trial results were reported and 62.9% afterward. To their surprise, the researchers reported in the Journal of the American Medical Assn., there were few differences between the two groups.

Before the COURAGE results were reported, 44.2% of the patients received optimal medical therapy before undergoing PCI and 63.5% received it afterward. After the trial, 44.7% received medical therapy before their procedure and 66% received it afterward. The increases were statistically significant because of the large number of patients in the study, the researchers said, but clinically insignificant.

“These findings represent a significant opportunity for improvement and a limited effect of an expensive, highly publicized clinical trial on routine clinical practice,” the authors wrote. Considering that PCI usually costs at least $40,000 and medical therapy is much cheaper, they concluded, increased use of medical therapy alone provides an option to significantly reduce health costs.