Tuesday, March 27, 2007

The study makes a convincing case for medical treatment of blocked heart arteries. Why I think it may change nothing, however?

The results of landmark trial COURAGE are in. I will easily give this study 4 PUTS. This study shows that patients with stable heart artery blockages do no better with stents than with medicines. This study deserves 4 PUTS because the results of this study should have a great impact on how we practice cardiology. While it should- I do think that the results of this trial may not change medical practice significantly any time soon- for the following reasons:
- Physicians acting in good faith feel very nervous leaving the blocked heart arteries alone once they are seen on the angiogram. The biggest concern is the possibility of blocked heart artery causing a heart attack
- The studies have shown that the arteries that are less than 50% blocked cause most of the heart attacks. However, we continue to be more nervous about the blockages that look ‘bad’ on the angiogram.
- Most of the patients do not feel comfortable leaving the blockages alone and do demand stents. Most of the physicians are not comfortable practicing paternalistic medicine.
- This study, while sending a clear message does leave a loophole. It says stents are justified if patient continues to have angina. In real practice, angina does not always come in the textbook form of typical chest pressure on exertion. Patients can have ‘twinges’, ‘sharp pains’ or ‘some breathing problems’ that are typically not thought to be due to the heart problem. However, in a patient who is being treated with medicines for blockages, these non-specific symptoms may make the patients as well as doctor nervous- ultimately leading to stent procedure.

Many people have asked me about the utility of stents ever since media discussed COURAGE trial. This is a good start. This study makes a great point. The real changes in practice however, will only come when patients start asking more about medicines as treatment for blockages. The patients’ awareness in turn will make physicians more comfortable not fixing every diagnosed blockage with stents or bypass. The COURAGE trial has brought along a great message. Lest we forget…
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