Stents that prop open a heart disease patient's blocked arteries don't offer significantly greater benefits compared to drug therapy alone, new research suggests, which could reduce the frequency with which doctors use this invasive, yet common, treatment.
American researchers have found that heart disease patients who had stents implanted and took medication experienced less chest pain in the first two years after they began treatment.
However, that benefit dissipated by the third year after starting treatment.
"What we found, somewhat to our surprise, is that both groups of people, whether they were treated with stenting or medical therapy, that over one to two months they all had substantial improvement in quality of life," lead study author, Dr. William Weintraub, told Â鶹´«Ã½.
"We also found there was some advantage in being treated with stenting but not over time."
"The conclusion is that people are going to get better, and there is some advantage to stenting but it is not that large. The majority of people can be treated with medical therapy alone."
The Courage study, as it is known, is published in the New England Journal of Medicine.
Earlier results from this study of 2,200 patients found that those with stents did not have reduced heart attack or death rates compared to patients who were on medication alone.
Hundreds of thousands of patients get stents every year, said Weintraub, cardiology chair at the Christiana Care Health System in Delaware.
However, there has been little research on how effective stents really are.
A stent is a wire mesh tube that acts like scaffolding, holding an artery open to improve blood flow to the heart muscle and relieve chest pain. A stent stays in the body permanently.
However, the findings suggest they should primarily be used on high-risk patients, while low-risk patients should be given drug therapy alone, said Dr. Robert Chisholm of Toronto's St. Michael's Hospital.
"So the Courage trial tells us that in this low-risk population we should try medical therapy first and if it fails we should move on to coronary stenting," Chisholm told Â鶹´«Ã½.
Chishold added that Canadian doctors are already treating fewer patients with stents and reserve them for higher-risk patients. This trial backs up that practice, he said.
With a report from CTV medical specialist Avis Favaro and senior producer Elizabeth St. Philip
Abstract:
Effect of PCI on Quality of Life in Patients with Stable Coronary Disease
William S. Weintraub, M.D., John A. Spertus, M.D., M.P.H., Paul Kolm, Ph.D., David J. Maron, M.D., Zefeng Zhang, M.D., Ph.D., Claudine Jurkovitz, M.D., M.P.H., Wei Zhang, M.S., Pamela M. Hartigan, Ph.D., Cheryl Lewis, R.N., Emir Veledar, Ph.D., Jim Bowen, B.S., Sandra B. Dunbar, D.S.N., Christi Deaton, Ph.D., Stanley Kaufman, M.D., Robert A. O'Rourke, M.D., Ron Goeree, M.S., Paul G. Barnett, Ph.D., Koon K. Teo, M.D., and William E. Boden, M.D., for the COURAGE Trial Research Group
Background: It has not been clearly established whether percutaneous coronary intervention (PCI) can provide an incremental benefit in quality of life over that provided by optimal medical therapy among patients with chronic coronary artery disease.
Methods: We randomly assigned 2287 patients with stable coronary disease to PCI plus optimal medical therapy or to optimal medical therapy alone. We assessed angina-specific health status (with the use of the Seattle Angina Questionnaire) and overall physical and mental function (with the use of the RAND 36-item health survey [RAND-36]).
Results: At baseline, 22% of the patients were free of angina. At 3 months, 53% of the patients in the PCI group and 42% in the medical-therapy group were angina-free (P<0.001). Baseline mean (�SD) Seattle Angina Questionnaire scores (which range from 0 to 100, with higher scores indicating better health status) were 66�25 for physical limitations, 54�32 for angina stability, 69�26 for angina frequency, 87�16 for treatment satisfaction, and 51�25 for quality of life. By 3 months, these scores had increased in the PCI group, as compared with the medical-therapy group, to 76�24 versus 72�23 for physical limitation (P=0.004), 77�28 versus 73�27 for angina stability (P=0.002), 85�22 versus 80�23 for angina frequency (P<0.001), 92�12 versus 90�14 for treatment satisfaction (P<0.001), and 73�22 versus 68�23 for quality of life (P<0.001). In general, patients had an incremental benefit from PCI for 6 to 24 months; patients with more severe angina had a greater benefit from PCI. Similar incremental benefits from PCI were seen in some but not all RAND-36 domains. By 36 months, there was no significant difference in health status between the treatment groups.
Conclusions: Among patients with stable angina, both those treated with PCI and those treated with optimal medical therapy alone had marked improvements in health status during follow-up. The PCI group had small, but significant, incremental benefits that disappeared by 36 months.
