Angioplasty no better than drugs
Study followed 2,200 patients. Those who had operation fared no better than subjects who followed health regimen
TOM BLACKWELL, CanWest News Service
Published: Tuesday, March 27, 2007
Deploying tiny balloons to unclog blocked arteries, they are small wonders of medical technology. But angioplasties are actually no more effective than intense drug and lifestyle treatment at preventing deaths and heart attacks among stable heart patients, a surprising new study has concluded.
Though tens of thousands of Canadians receive the procedure, which involves threading a tube through blood vessels from the groin to the heart, many could do just as well on aggressive medical therapy, researchers in Canada and the U.S. have found.
Until recently, cardiologists influenced by a "technology-driven world" would routinely order the procedure for virtually any patient with a blocked artery and angina, said Dr. Koon Teo, the McMaster University cardiologist who headed the Canadian portion of the study.
But the new evidence suggests it should probably be held off for such patients to see if other treatment works first, he said.
The findings ought to "give pause" to heart specialists and those they treat, said Beth Abramson, a Toronto cardiologist and spokeswoman for the Canadian Heart and Stroke Foundation.
"People would rather have an angioplasty than take a bunch of pills if they have heart disease, but we know that it is the long-term therapies that will make a difference," she said.
"Patients need to know that the newer technologies and quick fixes are not necessarily the best answers."
Applying results of the study, to be published this week in the New England Journal of Medicine, could shrink waiting lists for the more acutely ill cardiac patients who really benefit from angioplasty, Teo said.
And with the aging population, those patients are likely to quickly replace demand from stable patients receiving alternative therapy, he said.
"My junior colleagues say, 'Am I going to lose my job because of this?' " said Teo with a laugh. "In my mind, no - they're not going to lose their jobs."
Nevertheless, if doctors pay heed to the results, "substantial" savings for the health-care system could result, an editorial in the journal suggested.
The study noted one million of the procedures are performed yearly in the U.S. alone, and about 85 per cent are performed on patients with stable coronary artery disease.
Just under 40,000 angioplasties were done in Canada in 2000, said the Canadian Heart and Stroke Foundation.
The trial run by Teo and physicians at the Buffalo General Hospital looked at percutaneous coronary intervention, which encompasses both angioplasty alone and angioplasty accompanied by stents - metal mesh tubes inserted in the blocked artery to try to keep it clear longer.
There is no question the procedure prevents deaths and heart attacks among patients who have just had heart attacks or are experiencing other severe symptoms.
The trial looked at more stable patients with atherosclerosis, who may have a partially blocked artery and angina pain a few times a week but are otherwise functioning well.
One group of about 1,100 patients underwent angioplasties and received "optimal medical therapy" - comprehensive therapy with drugs to lower cholesterol and blood pressure and advice on better lifestyle. The other group of 1,100 had only the optimal medical therapy.
After following the patients for an average of 4.6 years, the researchers found there was no real difference between the two groups in terms of the rates of deaths caused by heart disease, heart attacks or strokes.
Both groups experienced a major reduction in the amount of angina - chest pain - they suffered, though the improvement was initially greater in the patients who had undergone angioplasty. By five years, however, angina rates were almost identical between the two groups.
Abramson said she was not surprised by the results. While an angioplasty quickly opens up one narrowed part of an artery, the disease affects the entire coronary artery and broader treatment is needed to ensure patients' long-term prognosis, she noted.
"Patients who are readers, who are often consumers, come into their physicians asking for that quick fix and asking for what they think may be the best, newest therapy," said Abramson, who practises at St. Michael's Hospital in Toronto.
"That newer intervention is not necessarily going to keep them alive any longer. And that's what this study shows - that long-term medical interventions, compliance with medications and making lifestyle changes are important."
National Post; CP contributed to this report