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Drug Therapy for Artery Disease Underused, Study Says
Date:5/10/2011

By Serena Gordon
HealthDay Reporter

TUESDAY, May 10 (HealthDay News) -- Fewer than 50 percent of people scheduled to have a stent placed in one of their coronary arteries for stable coronary artery disease received so-called optimal medical therapy -- drug therapy, such as statins -- before the procedure, according to new research.

This finding comes despite previous research, published in the New England Journal of Medicine four years ago, that found that optimal medical therapy was similarly effective to the stent procedure in preventing future cardiac problems.

That study was dubbed the COURAGE trial, and it included heart centers from across the United States. The study cost $33.5 million to conduct, and researchers hoped their findings would prompt more doctors to try medical therapy first in people with stable heart disease.

"The data shows that results are similar whether you treat with a stent or with medications in those with stable coronary disease," said the lead author of the new study, Dr. William Borden, a cardiologist at the Perelman Heart Institute at New York-Presbyterian/Weill Cornell Medical Center in New York City.

"When we looked at results before and after the COURAGE trial, the release of COURAGE didn't change practice patterns, and it seems that this is a real opportunity to look at how we deliver care to patients. For doctors, we need to make sure patients are on optimal medical therapy first. And, for policy makers, this study is an opportunity to look at how medical research trials are being translated into practice," Borden added.

Results of the new study are published in the May 11 issue of the Journal of the American Medical Association.

To get a better idea of how clinical trial results translate into practice, Borden and his colleagues reviewed data from the National Cardiovascular Data Registry on patients who were scheduled to undergo percutaneous coronary intervention -- stent placement. The registry included 1,013 U.S. hospitals, according to the study.

The registry also included data on 467,211 people who received a stent between 2005 and 2009. The new study included 173,416 people who received a stent before the COURAGE trial and 293,795 who received their stent after the COURAGE results were published.

Before COURAGE, 43.5 percent of patients were on optimal medical therapy before stenting. After the COURAGE trial, 44.7 percent received optimal medical therapy before undergoing a stenting procedure, the investigators found.

Optimal medical therapy generally included a beta blocker medication, a cholesterol-lowering statin drug and aspirin therapy, according to the study.

Borden said optimal medical therapy provides people with stable coronary artery disease the most benefit, particularly in the long-term. But it is not the first treatment of choice for people who are having a heart attack, he noted.

When the researchers behind the new study looked at how many people received optimal medical therapy after the stenting procedure both before and after COURAGE, they found similar results. Before COURAGE, 63.5 percent were given optimal medications, including an anti-platelet medication to discourage clot formation. And, after COURAGE, 66 percent were given optimal drug therapy, the findings showed.

That translates to a net benefit of 1.2 percent for medication therapy used before stenting, and 2.5 percent optimal drug therapy after stenting based on the COURAGE trial.

"I was surprised that in patients who have known coronary artery disease, who could benefit dramatically from being on the appropriate medications, that the right medicines weren't being used," said Borden.

Dr. James Slater, director of the cardiac catheterization laboratory at NYU Langone Medical Center in New York City, said, "The real message from COURAGE was that you don't need to use catheterization procedures in patients on optimal medical therapy for stable coronary artery disease."

Slater said that to really see the effects of COURAGE, the authors of the new study needed to include people who received optimal medical therapy and never needed to be referred for a stenting procedure.

"It would've been better if they also had people who didn't go on to have angioplasty," he said.

Borden said there are likely patients who are receiving the right drugs and are never referred for stenting, but it was important to look at the group referred for stenting as well. Ideally, all of the people referred for stenting should have already been placed on optimal medical therapy to see if their symptoms improved, he said.

More information

Learn more about angina from the American Heart Association.

SOURCES: William Borden, M.D., cardiologist, Perelman Heart Institute, New York-Presbyterian/Weill Cornell Medical Center, New York City; James Slater, M.D., director, cardiac catheterization laboratory, NYU Langone Medical Center, New York City; May 11, 2011, Journal of the American Medical Association


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