Angioplasty poster from the Parsemus Foundation.
Here’s more on the growing controversy surrounding unnecessary coronary stent procedures:
Consider a major cardiac study known as the COURAGE trial*, which signed up over 2,200 volunteers with stable angina, 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 treadmill 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 — medications to ease or prevent angina, to protect the heart and blood vessels, and in some cases to boost protective HDL cholesterol. Exercise and healthful eating were also stressed.
NOTE: for a sudden blockage of a coronary artery during heart attack or unstable angina, emergency artery-opening balloon angioplasty followed by the placement of a stent is the life-saving treatment of choice.
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 in cases of stable angina did NOT 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.
Most patients and doctors overestimate the benefits of angioplasty procedures, suggests a September 2010 survey of patients and their physicians at a Massachusetts hospital. Only 63% of physicians knew that except in emergencies, angioplasties only ease symptoms. And even those who were up-to-date apparently often did not inform their patients: 88% of patients who consented to the procedure mistakenly believed it would reduce their risk of having a heart attack.
In a study of more than 23,000 U.S. Medicare claims, more than half of patients had angioplasty done without first undergoing standard cardiac testing to prove it was necessary. And the rate of those procedures has increased 300% over the last decade.
A Consumer Reports Health article questions this common practice:
“Convenient? Sure. But necessary? Usually not. In non-emergencies, you have time to consult with a heart surgeon and even your primary-care doctor to discuss the options and arrive at the treatment strategy that’s best for you.”
I’ve referred previously here to the groundbreaking cardiac research of Germany’s Dr. Rainer Hambrecht whose 2004 study** was published in the heart journal Circulation. He compared two groups of heart patients with significant coronary artery blockages: one group had stents implanted, the other had no stents but a prescribed program of regular cycling exercise. Here’s what he found:
- Nearly 90% of heart patients who rode bikes regularly were free of heart problems one year after they started their exercise regimen.
- Among patients who had an angioplasty and stents instead, only 70% were problem-free after a year.
In 2009, Dr. Hambrecht and his team presented five-year follow-up findings to the European Congress of Cardiology meetings in Barcelona, confirming earlier study results that regular exercise training is superior to angioplasty at preventing subsequent cardiovascular events. Dr. Hambrecht said at the time:
“It’s difficult to convince people to exercise instead of having an angioplasty, but it works.”
In an interview with Heartwire, Dr. Hambrecht acknowledged that there are multiple forces working against a scenario in which regular exercise is prescribed instead of stenting.
“For one, patients are not motivated to take responsibility for improving their own cardiovascular health – even if it means better event-free survival.
“For another, encouraging exercising is financially less appealing for hospitals. That was my feeling – that hospitals were reluctant to participate in our study, because they derive revenue from revascularization procedures in their cath labs.”
Dr. Hambrecht also believes his research supports the call for cardiologists to take time between the diagnostic angiogram and the revascularization procedure to discuss lifestyle improvement options with the patient, rather than stenting every patient.
- Say what? Do Patients Really Hear What Doctors Tell Them?
- Your Health Care Decisions: Don’t Worry Your Pretty Little Head Over Them
- Stent-Happy Docs on Notice in Maryland Health Care Fraud Debate, from my other site, The Ethical Nag: Marketing Ethics for the Easily Swayed
- Cardiologists Accused Of Implanting Cardiac Stents That Weren’t Needed (The Nag)
- “You Can Lead a Cardiologist to Water, But, Apparently, You Cannot Make Him Drink” (The Nag)
* W.E. Boden. “Optimal Medical Therapy with or without PCI for Stable Coronary Disease”. New England Journal of Medicine, 2007; 356:150316.
** Hambrecht R, Walther C, Möbius-Winkler S, et al. “Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial” – Circulation 2004; 109:1371-1378
FEBRUARY IS HEART MONTH!
Do at least one thing smart for your heart, every day in February!