Better Long-Term Outcomes with Medications versus Angioplasty

There are some advantages to artery-opening angioplasty over medication treatment for people with heart disease, but those advantages disappear within three years, according to a report in the New England Journal of Medicine.

Angioplasty does offer a higher quality of life for months to a couple of years, says study leader Dr. William S. Weintraub, chief of cardiology at the Christiana Health Care System in Newark, Delaware.

In the COURAGE trial, the researchers tested angioplasty, with stent implants, against medication treatment for 2,287 people with stable coronary disease.

Earlier analysis found improved quality of life for those having the artery-opening procedure that is formally called percutaneous coronary intervention (PCI).

The new report found that by 36 months, there was no significant difference in health status between the two treatment groups.

“What one can say is that for people with chronic, stable coronary disease, PCI can be deferred,” Dr. Weintraub says. “They can continue on medication aimed at their specific risk factors – hypertension, lipid disorders, diabetes – and should be encouraged to have a good lifestyle, with exercise, smoking cessation, and weight control.”

Doctors Assess Needs

A decision to have PCI can depend on how an individual feels, says Dr. Weintraub.

“If people say, ‘My pain is so bad I can’t function,’ that is one thing. If people say, ‘I have angina, but I’m doing OK,’ that’s another,” he says.

Angina is the chest pain that is a chief symptom of coronary disease.

Cost could be a factor in some decisions, notes Dr. Weintraub. PCI is more expensive than medication therapy, but the current report does not mention money.

However, a preliminary cost-benefit analysis presented by Dr. Weintraub last November found that “PCI adds about $10,000, without any significant gain in years of survival or quality of life.”

The cost of one year of life added by PCI varies from $150,000 to $300,000, the analysis found.

The cost of PCI versus medication treatment must be considered “by society as a whole,” he says. “But when a doctor talks to a patient, the doctor is an advocate for that patient.”

An individual’s health insurance status can matter, Dr. Weintraub acknowledges.

“Paying the cost out of pocket gives one a different point of view,” he says.

The attitude of medical insurance providers does matter, says Dr. Eric D. Peterson, at the Duke Clinical Research Institute. Insurance companies now are quite willing to pay for PCI, and “until that category is changed, the effect of this study will be modest,” he says.

Medical Therapy for Stable Heart Disease

The COURAGE results show that PCI should not be the treatment of choice for people with stable heart disease, says Dr. Peterson.

“We have justified angioplasty for years by saying it is of great benefit to patients,” he says. “This study shows no survival benefit and shows that the benefit in regard to symptom relief is temporary. Medical therapy should be considered for all patients with stable angina, unless they have severe pain when diagnosed.”

The fact that 21 percent of those in the COURAGE trial who started on medication treatment eventually had PCI shows that a decision on surgery can safely be delayed, he says.

The hazards as well as the benefits of PCI should be considered when a decision is made, notes Dr. Peterson.

Of 1,000 persons undergoing PCI, two will die, 28 will have heart attacks related to the procedure, 60 to 90 will have improved symptom relief, and 800 will have no noticeable benefit above that given by drug treatment, his editorial explains.

Always consult your physician for more information.

Triglycerides Linked to Risk for Heart Disease

High levels of triglycerides are strong predictors of cardiac trouble and this strengthens the case for including measurement of the blood fats in prevention programs, says a study in the Journal of the American College of Cardiology.

“Triglycerides traditionally have been viewed as second-class citizens,” says lead author Dr. Michael Miller, at the University of Maryland Medical Center.

“LDL cholesterol has always taken center stage,” says Dr. Miller. “We know that LDL is intimately involved in bringing cholesterol to scavenger cells, which deposit them to form plaques in the arteries.

“This study shows that triglycerides in and of themselves are also lipids to blame,” notes Dr. Miller.

Under 150 on Triglycerides is Best

The original study was designed to test the effectiveness of two LDL-lowering statins called Pravachol® and Lipitor® in reducing recurring coronary disease after a heart attack.

The new study went over the data on the 4,162 participants in the trial, looking at the association between triglyceride levels and the incidence of heart problems and death.

“The patients who had heart attacks came back after 30 days,” says Dr. Miller. “We measured LDL levels and triglyceride levels and followed them over the next two years, evaluating for the occurrence of new events and death. If a patient had triglyceride levels below 150 [milligrams per deciliter], there was a 27 percent lower risk of having a new event over time,” he says.

“After multiple adjustments for such things as age, diabetes, high blood pressure, and obesity, the risk reduction was 20 percent,” Dr. Miller explains.

Unlike LDL cholesterol, for which there is a recommended blood level of 70 or below, there is no recommended blood triglyceride level but 150 milligrams per deciliter or below is “considered as desirable,” says Dr. Miller.

When the participants were divided into four groups on the basis of both LDL and triglyceride levels, those in the group with under 150 for triglycerides and under 70 for LDL did the best.

They had a 28 percent lower risk than those in the group with the highest readings for both LDL and triglycerides, he says.

“At the present time, we don’t have a recommendation for triglyceride lowering, so the next logical step is a study to determine whether lowering triglycerides and LDL reduces risk more than lowering LDL alone,” he says. Two such studies are in progress, he notes.

Mediterranean Diet a Good Approach

Previous research has already pointed toward such a connection: A study that appeared in the medical journal Neurology last December found a link between triglycerides and stroke risk.

And research published in the Journal of the American Medical Association (JAMA) last July showed that when high triglyceride levels showed up in nonfasting cholesterol tests, there was an increased risk for a future heart attack.

Dr. Leslie Cho of the Women’s Cardiovascular Center at the Cleveland Clinic, notes that the new report “is not a huge surprise.”

She says, “The unique thing about this study is that even if you control bad LDL cholesterol to less than 70, you still need to look at triglycerides.”

The problem with triglycerides is that “they are the most unstable fats in the body,” so that at least two readings are needed to get an accurate measure of blood levels, she explains.

Dr. Miller says, “I am proactive about both LDL cholesterol and triglycerides.”

Several measures can be taken to lower triglyceride levels – many of them are already recommended on general principles for reduction of coronary risk.

One is to eat a Mediterranean diet, rich in fish. Omega-3 fatty acids can lower triglyceride levels, as can niacin, and exercise has a beneficial effect, says Dr. Miller. Statins also have some triglyceride-lowering effect, he notes.

“If you can effectively get both LDL cholesterol and triglycerides down, you are going to do better,” says Dr. Miller.

Always consult your physician for more information.