Doctors Debate Drugs vs. Surgery for Angina

FRIDAY Sept. 14, 2007 -- Controversy still swirls around how doctors can best treat patients with the chest pain called stable angina, with some physicians favoring the use of drugs while others vote for surgery.

The results of a major trial, called the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE), seemed to indicate that drug therapy was preferable to angioplasty, since only drug therapy reduced patients' risk of heart attack and death. Those findings were published in March.

But now, researchers taking a fresh look at the data say the opposite may true. They find that angioplasty is usually the best first line of defense against angina.

Will that settle the issue? It's doubtful, experts say.

"There is a lot of debate on both sides of the issue," said Dr. George A. Diamond, a professor of medicine at the University of California, Los Angeles, and co-author of an accompanying journal editorial.

There's a large group of people who believe that these people need to be treated to remove their symptoms completely, and the best way to do that is with interventional procedures such as angioplasty and stenting, Diamond said.

"However, there is another group of individuals who feel the problem can be handled medically," Diamond said.

In the new review of the COURAGE data, Dr. Dean J. Kereiakes, from Christ Hospital Heart and Vascular Center/The Lindner Research Center in Cincinnati, and colleagues come down on the side of angioplasty as first-line treatment for patients with stable angina.

The study authors noted that COURAGE showed significantly better reduction in angina and a reduction for the need for repeat angioplasty or other invasive procedures compared to drug interventions. In addition, patients treated initially with angioplasty had no increased rates of heart attack or death compared with patients treated with drugs alone.

In the second place, the trial confirmed earlier studies that indicated that not doing angioplasty to open all the patient's narrowed coronary arteries was linked to a poorer outcome and the need for more invasive procedures.

Third, despite intensive medical therapy for stable coronary disease patients -- which Kereiakes sees as unrealistic -- "severe or progressive symptoms led to a surprisingly high rate (32 percent) of 'crossover' to revascularization [surgery] in patients initially assigned to medical therapy alone," they noted in their paper in the Oct. 16 issue of the Journal of the American College of Cardiology, released Friday.

Fourth, Kereiakes' team believes that the clinical benefits of drug therapy plus angioplasty give patients, particularly those with disease in more than one vessel, the biggest benefit in terms of reducing chest pain.

Still, a case-by-case approach may be best, the research team said.

"The choice of therapy (s) for each individual patient must be made based on coronary anatomic suitability and in the context of the patient's lifestyle, functional capacity, level of symptom limitation, and their ability (physically, emotionally, and financially) to take the prescribed treatment," Kereiakes' group noted. "If PCI (angioplasty) revascularization is performed, this procedure should be done using the most complete and effective tools and always in addition to (rather than in place of) medical therapies that reduce [cholesterol] plaque progression," they concluded.

Despite these findings, Diamond said that the COURAGE trial showed that drug therapy was as effective as drug therapy plus angioplasty for patients with stable angina. "Angioplasty provided no additional benefit over optimal medical care," he said. "That gores the ox of those who believe strongly in angioplasty."

Diamond's own stance? He believes angioplasty is the correct initial treatment for patients who have suffered a heart attack but not for patients with chronic stable angina.

"Patients with mild angina should be tried on medical therapy alone," he said. "The evidence has shown that there is a reasonable level of expectancy that that will relieve the symptoms. In addition, it has proven benefit in lowering the risk of heart attack and death, which has not been shown for angioplasty."

Which treatment any patient may get is dependent on the doctor he or she sees, Diamond added. "Truth be told, aside from the emotional belief that opening the vessel gives a better-looking X-ray, the studies don't bear that out," he said. "If you go to a physician who believes in these procedures and does them himself, you are much more likely to get a procedure rather than medical therapy."

Financial incentives also encourage that, Diamond said.

"We get paid a lot more for doing procedures than we do for giving sage advice and simply writing a few prescriptions," he said.

Despite the data, Diamond expects the debate to continue so long as treatment guidelines are ambiguous and don't reflect the latest evidence for the best medical care. "We need to realign the current practice guidelines to be consistent with the evidence," he said.

Patients with angina should have an angiogram before any treatment decisions are made, Kereiakes said. "You have to individually assess every patient to determine their ability emotionally and financially to take the prescribed treatment," he said.

Kereiakes is concerned that patients on drug treatment alone do not comply with their regimen. It doesn't happen in the real world, he added.

Medication and angioplasty are complementary therapies, Kereiakes said. "Most patients with stable angina can't be managed by drugs alone," he said. "But treatment must be individualized."

Posted: September 2007


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