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.

If you are an older American with no major health problems, chances are about one in 10 that you have had a stroke and did not know it, according to a report in the medical journal Stroke.

It was probably not severe enough to cause recognizable symptoms, such as vision problems, facial weakness, or trouble walking, but it was still a blockage of a brain artery, and it reduced your thinking powers just a bit.

That estimate comes from a new study of 2,040 people, average age 62, in the long-running Framingham Offspring Study.

Magnetic resonance imaging (MRI) scans showed that 10.7 percent of them had experienced what study author Dr. Sudha Seshadri, at Boston University, calls “a silent brain infarct.”

It is the cerebral equivalent of what physicians call a myocardial infarct – blockage of a blood vessel that causes damage to heart tissue. In the case of a silent stroke, the blockage and the damage occurs in the brain, without symptoms.

TIA Has Symptoms, Silent Stroke May Not

A silent stroke is different from a transient ischemic attack (TIA), a momentary loss of brain function, says Dr. Seshadri. A TIA causes some symptoms, while a silent stroke, by definition, does not.

But both are warning signs to pay attention to the well-known risk factors for stroke, such as cholesterol levels, blood pressure, obesity, and smoking.

The incidence found in the Framingham Offspring study “was within the ballpark of what prior studies have suggested,” notes Dr. Seshadri.

“But this was a group of people who were younger than in most of the prior studies,” she says. “The fact that one in 10 persons had silent attacks that had subtle side effects on the brain is something we should be concerned about and should address.”

The effects of a silent brain infarct show up on an MRI scan as “small lesions in various parts of the brain,” says Dr. Seshadri. “We can’t tell from that whether they had a symptomatic attack.”

And the MRI scans give no clues as to when the silent stroke occurred.

Testing showed that “on average, compared to age-matched controls, those with lesions do have subtle signs, such as loss of flexibility of talk,” she says.

Address Risks Through Lifestyle Changes

The incidence seen in the study did not startle Dr. Claudette Brooks, at West Virginia University Health Sciences Center.

“When I look for the cause of headaches and similar problems, it doesn’t surprise me when I see these lesions, and other colleagues tell me they see them,” says Dr. Brooks.

An even higher rate of silent strokes might be expected in a study of African Americans, she notes.

“They have a higher incidence of hypertension [high blood pressure], atherosclerosis, and hyperlipidemia [excess blood fat],” says Dr. Brooks.

Nothing special needs to be done to reduce the risk of silent stroke, both physicians say.

“I wouldn’t recommend that people rush out to have an MRI,” says Dr. Seshadri. “It’s up to the medical and public health community to emphasize the importance of controlling risk factors.”

“The whole thing boils down to modifying risk factors,” explains Dr. Brooks. “If you don’t have risk factors such as high cholesterol, obesity, and diabetes, try to keep yourself out of the group that does. If you do, modify them by keeping blood pressure and cholesterol down, things like that.”

Always consult your physician for more information.

Online Resources

(Our Organization is not responsible for the content of Internet sites.)

American Heart Association

American Stroke Association

National Heart, Lung, and Blood Institute (NHLBI)

National Institute of Neurological Disorders and Stroke

National Stroke Association

Stroke – Prevalence and Correlates of Silent Cerebral Infarcts in the Framingham Offspring Study