For Coronary Artery Disease, Meds as Effective as Stents

VIDEO: Dr. Michael DiMaio questions the use of stents for stable heart disease.
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Inserting stents to open a blocked artery is a common way to treat coronary artery disease. But increasing evidence suggests the procedure is not as beneficial as patients and some doctors might believe.

An analysis published Monday in the Archives of Internal Medicine found that using stents to repair arteries narrowed by plaque was no better than using standard medications to treat patients with stable coronary artery disease.

Patients with the condition usually have angina, or chest pain, at certain times of physical activity or emotional stress. The pain is the result of blocked arteries, which can prevent adequate blood and oxygen from getting to the heart muscle, causing pain.

To relieve the condition, doctors will open the blockages with stents, metal mesh tubes that can be plain or coated with medication to keep the artery open.

Some recent analyses have pointed to the benefit of stents in treating coronary artery disease, but the authors of the current analysis point out that that data came from the 1980s and 1990s, when patients were often treated with balloon angioplasty rather than stents, and when modern drug treatments, such as statins, beta blockers and ACE inhibitors were not yet available.

"Medical management of coronary artery disease with aggressive statin therapy and other medications is much better now than it was in the past," said Dr. Jon Resar, director of interventional cardiology at Johns Hopkins Hospital in Baltimore.

But the popularity of stents persists, despite mounting evidence that less invasive, cheaper drug treatments are just as effective.

The current report analyzed eight clinical trials and a total of 7,229 patients, half of whom received stents and half of whom received medical therapy alone. The treatment outcomes were virtually the same for both groups: 8.9 percent of patients with stents died, compared with 9.1 percent of patients on medication only; 8.9 percent of the stent patients had nonfatal heart attacks, compared with 8.1 percent of the medicated patients.

Nearly 31 percent of patients who took medication eventually got a stent, and more than 21 percent of patients with one stent had to get another stent.

The results of the analysis don't come as a surprise to many cardiologists, who say the knowledge that stents aren't effective in preventing death or heart attacks is widespread. Many treatment guidelines already recommend giving medications to patients with coronary artery disease before turning to stents.

What is surprising, experts say, is that so many physicians continue to recommend and implant stents to treat stable coronary artery disease without first trying to treat patients with medication.

Dr. David Fischman, co-director of the cardiac catheterization lab at Thomas Jefferson University in Philadelphia, said there was never any evidence that they reduce the risk of death or prevent heart attacks in patients with stable disease.

"The knowledge, however, had gone unheeded by physicians and patients for a number of reasons," he said.

Some say the way the U.S. health care payment system encourages hospitals and doctors to perform revenue-generating procedures rather than prescribing medications. Procedures to insert stents can cost as much as $50,000.The authors of the current analysis estimate that avoiding stents by treating patients with medication only could save the health care system $9,450 per patient.

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