Costly heart treatment in doubt

James Grady of Raleigh got an angioplasty and a stent last December to clear a blocked artery, certain that the treatment would prevent a heart attack. More than a million Americans have the same procedure each year with the same expectations.

Grady and other stable heart patients would do just as well taking a few pills and skipping the procedure, according to a major new study, conducted in part at the Durham VA Medical Center and released Monday to the nation's cardiologists.

The findings could cool cardiologists' enthusiasm for angioplasty and stents -- treatments some already think are overused but highly profitable. Angioplasty procedures costs roughly $35,000 at Triangle hospitals, while popular heart pills are often available cheaply as generics.

According to the medical trial, patients who took heart medicines and had arteries cleared and propped open with stents lived no longer and were no less likely to suffer heart attacks than patients who took only heart pills, including statin drugs, beta-blockers, nitrates and plain old aspirin. The research was published online Monday in the New England Journal of Medicine.

"I'm surprised at that," said Grady, 71. He was pleased with his angioplasty, which he said quickly eased his shortness of breath. "From my standpoint, it was the thing to do."

Angioplasty is considered a lifesaver for patients having a heart attack, because it quickly restores blood flow. But the new study shows that it doesn't deserve credit for preventing heart attacks -- the most common reason it is used in patients.

As the first head-to-head comparison of stent angioplasty vs. medication alone, the trial enrolled nearly 2,300 patients at 50 hospitals across the country, including the Durham veteran's hospital. The study was funded by the U.S. Department of Veterans Affairs and several drug companies. To participate, patients had to have chronic chest pain, one or more arteries at least 70 percent clogged, yet be in no immediate danger of heart attack.

The surprise

Dr. William Boden, a cardiologist at Buffalo General Hospital/Kaleida Health in Buffalo, N.Y., and lead investigator of the trial, said one of the most important revelations is not that angioplasty and stent performed below expectations, but how well medication performed. He said cardiologists and patients in recent years have looked at medicine as somehow inferior to high-technology procedures.

"Medication therapy has gotten a bad rap," Boden said during a conference call Monday. "It kind of seems old-fashioned, it kind of seems ho-hum."

The new study shows, he said, that drugs are a "viable third option" to angioplasty and heart-bypass surgery -- although angioplasty proved better at relieving symptoms and improving the quality of life.

Still, researchers said the drug results were impressive for reducing chest pain. Five years out from treatment, 72 percent of medicine-only patients reported they were pain free, compared to 74 percent of the angioplasty patients.

"It opens the therapeutic options to patients," Dr. Sidney Smith, a cardiologist at UNC Hospitals in Chapel Hill and former president of the American Heart Association. "This brings hope to a lot of patients who are not candidates for angioplasty."

Smith does angioplasties, but also prescribes medicine to his patients. He said the drugs' advantage may be that they work on the entire circulatory system, while angioplasty and stents open just one blockage.

Smith, who leads a committee that writes national guidelines for how angioplasty and stents are used, said the findings could prompt cardiologists to curb their use of the increasingly popular -- and costly -- combination.