Most effective treatments for people with coronary artery disease

Medication, angioplasty or surgery? For some heart disease patients, there's no clear-cut choice. The key to getting the best care is to follow your individual doctor's advice, new research shows.

The research, conducted at the Heart Institute of the University of Sco Paulo Medical School in Brazil, appears in the Sept. 5, 2006, edition of the Journal of the American College of Cardiology.

For the study, researchers reviewed data collected during the Medicine, Angioplasty or Surgery Study II (MASS II) to determine how physician-recommended care affected patient outcomes one year after treatment. All patients were diagnosed with severe coronary artery disease affecting at least two blood vessels but not yet causing a loss of heart function. Coronary artery disease occurs when a buildup of cholesterol in the arteries prevents oxygen-rich blood from nourishing the heart muscle.

"We still currently do not know which is the best therapeutic option for patients with multivessel chronic coronary artery disease and a normal ventricular function," said Whady Hueb, MD, PhD, a cardiologist at the University of Sco Paulo Heart Institute (InCor). "I think our study offers additional information and reassurance for both doctors and patients that, at the end of the decision-making process, what the doctor and patient agree is the best option in most cases really is the best option."

Dr. Hueb is senior author of the new study and principal investigator of MASS II, a randomized, controlled clinic trial looking for new ways to determine the most effective treatments for people with coronary artery disease.

For the study, 611 patients met with their individual cardiologists for evaluation. The physicians examined them and then, after conferring with a second cardiologist, recommended one of the three potential treatments: medication, noninvasive angioplasty using balloons and/or stents to open clogged arteries, or coronary artery bypass graft (CABG) surgery to reroute blood through new vessels grafted into place.

After the cardiologists made their recommendations, the patients were randomly assigned to receive a treatment. After one year, all records were reviewed to determine the percentages of patients who had died, experienced heart attacks or required additional procedures to treat blocked arteries.

According to the research, patients assigned to receive their physician-recommended treatment showed a significantly lower incidence of problems. In contrast, patients assigned to a different course of treatment experienced a statistically significant increase in negative events (p = 0.02).

The most common - and only statistically significant - issue affecting this second group was the need for additional procedures to treat blocked arteries (p = 0.007.) No significant differences were found in either heart attack or death rates.

"Our data are a reminder that physician judgment remains an important predictor of outcomes," said Alexandre C. Pereira, MD, a cardiologist at the University of Sco Paulo Heart Institute and one of the study's co-authors.

"We should always remember that the therapeutic decision option is the final result of a complicated equation that uses both objective and subjective variables, which will not necessarily be acquired by lab tests, imaging exams or objective questions in a clinical questionnaire," Dr. Pereira said. "In this scenario, physician judgment - with all of the subjectivity that it may imply - still appears to be the best test or exam that a patient may have."

Ori Ben-Yehuda, MD, associate professor of medicine and director of coronary care at the University of California, San Diego, Medical Center, was not connected with the research but said it highlights why medicine will always be "an art not a science," and provides an intriguing new avenue for the future research of complicated medical conditions.

"The idea is quite ingenious and has never been done before," said Dr. Ben-Yehuda, a deputy editor of the Journal of the American College of Cardiology and author of an editorial that will accompany publication of the research. "The concept of recording a physician's judgment before conducting the randomization process to allocate patient treatment allows us to evaluate whether there are differences in outcomes based on that judgment.

"In other words, a physician may notice a lot of little things that add up to one big thing," Dr. Ben-Yehuda said. "This big thing may go against the scientific formula routinely used to determine the patient's care. In the final analysis, this research shows that even in this day and age, physician judgment continues to be critical in patient care."

Neither Dr. Hueb nor Dr. Pereira reports any disclosures in connection with this research. MASS II was funded by an internal grant from the University of Sco Paulo Heart Institute.