Drugs as good as stents for many heart patients

By MARILYNN MARCHIONE
15 aug 2008--People with chronic chest pain who are not in big danger of a heart attack now may have even less reason to rush into an artery-opening angioplasty: There's more evidence drugs should be tried first and often are just as effective.
The slim early advantage for angioplasty at relieving pain in these non-emergency cases starts to fade within six months and vanishes after three years, according to a new report from a landmark heart study.
That is sooner than the five years doctors estimated last year after their first analysis of the study. The new information comes from patients' own reports of how they fared after treatment. Results are in Thursday's New England Journal of Medicine.
"This study should be enlightening and practice-changing for doctors and patients alike," and should lead more to try drugs before resorting to the $40,000 heart procedure, said Duke University's Dr. Eric Peterson, who co-authored an editorial in the medical journal.
The number of angioplasties has been falling since the first results from this big study came out in 2007, according to new figures requested by The Associated Press from an American College of Cardiology database.
Angioplasty remains the top treatment for people having a heart attack or hospitalized with worsening symptoms. It involves using a tiny balloon to flatten a clog and propping the artery open with a mesh tube called a stent.
However, at least a third of angioplasties are done on people not in imminent danger, to relieve chest pain. These patients are no more likely to die or suffer a heart attack if initially treated with drugs alone, the big 2,287-patient study revealed.
Still, angioplasty's fans tout it as a quick fix that improves quality of life. That benefit is fairly small and short-lived, compared to good medication use alone, the new report found.
Researchers did followup health surveys of about 70 percent of the study's participants. At the start, 78 percent had chest pain.
Three months after treatment, 53 percent of patients who had angioplasties plus drug treatment and 42 percent of the drugs-alone patients were free of chest pain. Both groups continued to improve, and the gap started to narrow within six months. After three years, their scores on chest pain, quality-of-life and treatment satisfaction did not significantly differ.
"Patients get better," regardless of which initial treatment they have, said study leader Dr. William Weintraub of Christiana Care Health System in Newark, Del.
One exception: Those who started out with more severe chest pain fared better with angioplasty. And not everyone did well on drugs alone — about one-third ultimately needed an angioplasty or heart bypass surgery.
The study was funded by the U.S. Department of Veterans Affairs, the Medical Research Council of Canada and a host of drug companies. Many of the researchers have consulted for drug makers, and many of the study's critics have consulted for stent makers.
People in the study were properly tested to ensure they were medically stable, said Dr. Spencer King, a cardiologist at St. Joseph's Heart and Vascular Institute in Atlanta and past president of the cardiology college.
"My greatest fear" is that some patients now may be given medications without adequate testing to show angioplasty can safely be delayed, he said.
The study patients also received an ideal mix of medicines, potentially including aspirin, cholesterol-lowering statins, nitrates, ACE inhibitors, beta-blockers and calcium channel blockers.
Not all patients do, especially when doctors are paid more to do an angioplasty than for the many office visits needed to get the meds right.
"It's a tricky business and it requires a lot of close followup," said Dr. W. Douglas Weaver, a heart specialist at Henry Ford Health System in Detroit and president of the cardiology college.
About 1 million angioplasties are done in the United States each year.
The number started to decline before the study came out, because of safety worries about certain stents, and continued to fall after it, said Dr. Ralph Brindis, a California heart specialist who heads the cardiology college's cardiovascular data registry.
The proportion of angioplasties done on people with chronic but stable chest pain dropped from 18 percent in early 2005 to just over 15 percent by March 2008, the registry shows. Started 10 years ago, it now includes information on about 530,000 angioplasties per year — roughly 60 percent of the national total.
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On the Net:
New England Journal: http://www.nejm.org