The cost of PCI versus drug treatment must be considered "by society as a whole," he said. "But when a doctor talks to a patient, the doctor is an advocate for that patient."
An individual's health insurance status can matter, Weintraub acknowledged. "Paying the cost out of pocket gives one a different point of view," he said.
The attitude of medical insurance providers does matter, said Dr. Eric D. Peterson, a professor of medicine at the Duke Clinical Research Institute. Insurance companies now are quite willing to pay for PCI, and "until that category is changed, the effect of this study will be modest," he said.
The COURAGE results show that PCI should not be the treatment of choice for people with stable heart disease, Peterson said.
"We have justified angioplasty for years by saying it is of great benefit to patients," he said. "This study shows no survival benefit and shows that the benefit in regard to symptom relief is temporary. Medical therapy should be considered for all patients with stable angina, unless they have severe pain when diagnosed."
The fact that 21 percent of those in the COURAGE trial who started on drug treatment eventually had PCI shows that a decision on surgery can safely be delayed, he said.
The hazards as well as the benefits of PCI should be considered when a decision is made, Peterson said. Of 1,000 persons undergoing PCI, two will die, 28 will have heart attacks related to the procedure, 60 to 90 will have improved symptom relief, and 800 will have no noticeable benefit above that given by drug treatment, his editorial said.
Another paper in the same issue of the journal repor
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