Angioplasty doesn't outweigh medicine in study

In what some leading cardiologists are calling a "blockbuster" study, new research could alter the approach to treating patients who have cardiovascular disease but may not be at immediate risk of heart attack or stroke.

Co-authored by UK HealthCare's Linda and Jack Gill Heart Institute cardiologist Dr. David Booth, results of a five-year study showed that stable heart patients received no significant benefit in undergoing angioplasty when compared to patients treated with medication alone. The study, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, is published in the current issue of the New England Journal of Medicine and was presented at the American College of Cardiology's annual scientific sessions in New Orleans.

More than 2,000 patients at 50 sites in North America, including the Lexington VA Medical Center at the University of Kentucky, were followed for four and a half years. The rate of death, heart attack and stroke was 19.5 percent in patients who had medication alone and 20 percent in patients who had percutaneous cardiac intervention, or PCI (procedures that involve clearing blocked vessels by inserting a catheter into a blood vessel, usually in the groin or arm, allowing the physician to access the blockage). While the study did show that patients who underwent PCI had the most relief from symptoms of angina, or mild chest pain that usually occurs with exertion and is relieved with rest and medication, patients who received medication alone also showed significant improvement in symptoms.

The study indicates that intervention can be safely deferred in stable heart patients, who in most cases may be treated initially with medication to lower cholesterol and prevent heart attack.

"The purpose of treating patients is to make them feel better, live longer, or both. For patients with stable, and I emphasize stable, symptoms and reasonable heart strength, the COURAGE trial shows that an initial strategy of aggressive medical treatment is equally as effective as angioplasty and stenting in the prevention of fatal and nonfatal heart attack and hospitalization," Booth said.

While the findings are expected to significantly impact patient care practices in some settings, as noted in an accompanying editorial in NEJM, the study supports the approach to patient care at the University of Kentucky, notes Dr. David Moliterno, UK College of Medicine chief of cardiovascular medicine and co-director of the UK Gill Heart Institute. "UK has been carefully and cautiously approaching patients in the treatment of heart disease as we endeavor to provide the best medical care available," Moliterno said. "Because of our position of prudence and patient care first, we were among the top enrolling centers in this study and a co-author of the findings."

Booth and Moliterno are among a group of UK cardiologists whose research findings are being presented to thousands of physicians at the ACC scientific sessions this week.