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.

Some Fats Actually May Help the Heart

Fewer than half of Americans realize there are two types of dietary fat that actually help their hearts, a new survey shows.

So, while many have heeded the warnings about the cardiovascular dangers of trans fats and saturated fats, the American Heart Association (AHA) now thinks people need to pay more attention to the cardiovascular benefits conferred by polyunsaturated and monounsaturated fats.

As a result of its recent survey, the AHA’s new Face the Fats campaign has harnessed the power of the Internet to encourage people to view these lesser known fats with new respect.

“We’re trying to take education to the next level and say when you have the opportunity to choose, choose the better fat, not the bad fat,” says Dr. Clyde W. Yancy, medical director of the Baylor Heart and Vascular Institute in Dallas and the incoming president of the AHA.

HDL Continues to “Sweep” the Bad Away

The campaign’s Web page presents information at varying levels of sophistication.

The pages include an interactive quiz on fats, menus, recipes, and a Fats 101 course. A Fats Translator calculates a body-mass index from the input of height, weight, age, and level of activity.

The index is a scale ranging from underweight to obesity.

The AHA decided to go digital in this phase of its campaign because “the Web really is becoming the world’s premier information source, so we have to be there,” adds Dr. Yancy.

“When we have lots of polyunsaturated and monounsaturated fats in our diet, our HDL cholesterol goes up and helps protect our arteries from clogging up and hardening,” explains Lona Sandon at the University of Texas Southwestern Medical Center in Dallas.

“HDL kind of acts like a broom and sweeps up the artery-damaging molecules and takes them away,” she says.

Trans fats and saturated fats are more able to stick to blood vessel walls and harden arteries, adds Dr. Yancy.

This process can lead to the rupture of an artery or obstructed blood vessels that can cause heart attacks, strokes, or blood vessel disease.

Moderation on all Fats Advised

Sandon supports the idea of greater education on the different forms of dietary fat.

“I think it’s still very confusing for people,” she says. “They don’t know if they should be eating low fat, what kind of fat.”

She also advises moderation in consumption of any kind of fat. All fats have nine calories per gram, she explained, so even too much of the better fats can lead to weight gain. “They’re healthy, but you can’t go wild with them,” she says.

The Face the Fats campaign is funded by $7 million received from McDonalds USA as part of the settlement of a California class action lawsuit brought by a consumer advocacy group, bantransfat.com, according to the AHA.

McDonald’s recently announced that it has eliminated trans fats from its fried foods by changing to a canola-based cooking oil.

Always consult your physician for more information.