More drugs, fewer stents still needed for heart patients

Kathleen Blanchard's picture
Optimal medical therapy for heart patient
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Researchers say heart patients are still receiving stents, despite evidence that medications lead to the same outcomes.

In a 2007 study, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, patients given optimal medical therapy for angina from heart blockages had the same clinical outcomes as those receiving percutaneous coronary intervention (PCI) with stents. In a new review, researchers say the trial finding did little to change clinical practice.

Since the $33.5 million trial results were published, less than half of patients with coronary artery disease were on medications like aspirin, beta blockers and statins before they received a stent, found in the new study. Less than one third received optimal medical therapy after the procedure.

The study review was conducted by New York-Presbyterian Hospital/Weill Cornell Medical Center and included an analysis of 500,000 patient cases.

Dr. William Borden who led the study said the review should be a “call” to policy makers and clinicians who have an opportunity to improve quality of patient care by implementing the findings.

The COURAGE study results, which showed cardiac stents didn’t reduce the risk of heart attack, stroke or death, compared to medications, was met with some resistance from Cardiologists who recognize the immediate improvement in patient symptoms when blood flow is restored to the heart with PCI.

Nevertheless, the study was anticipated to reduce the number of stenting procedures performed that carry risk of bleeding, thrombosis around the stent site and higher cost.

The researchers for the current study say it’s time to implement the findings from the trial. They also say patients need to be aware of their treatment options.

Since the COURAGE study was published, optimal medical therapy before a stent rose 1.2 percent. After stenting, the increase was 2.5 percent.

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Dr. Borden said, "While this is a statistically significant result given that thousands of patients were included in the study, it is not clinically significant," he says.

For the review, 467,211 patients were tracked for changes in medical therapy before and after stenting before and after the study release; between 2005 and 2009.

The authors suggest more collaboration might be needed between primary physicians, cardiologists and nurses as well as educating physicians.

Dr. Alvin I. Mushlin, chairman of the Department of Public Health at Weill Cornell Medical College and public health physician-in-chief at New York-Presbyterian Hospital/Weill Cornell Medical Center says there’s “opportunity” to improve patient care.

He suggests looking at: how hospitals and physicians work together, how the incentive system is structured, how medical care is paid for, and how access to health care can be assured."

One way to do that he says, is with a Patient-Centered Outcomes Research Institute, funded by the Affordable Health Care Act.

The COURAGE trial did little to change clinical practice since it was published in 2007. The researchers say implementing the findings from the study by optimizing medical therapy before cardiac stenting, educating patients about choices for treating coronary artery disease; teamwork and physician education would improve quality of patient care.

JAMA. 2011;305(18):1882-1889. doi: 10.1001/jama.2011.601
"Patterns and Intensity of Medical Therapy in Patients Undergoing Percutaneous Coronary Intervention"
William B. Borden et al.

Image: Wikimedia Commons

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