Author Insights: Stenting Not Appropriate for Treating Stable Coronary Artery Disease

William E. Boden, MD, of the Samuel S. Stratton VA Medical Center in Albany, NY, said percutaneous coronary interventions are not superior to optimal medical therapy in treating patients with stable coronary artery disease. (Image: Samuel S. Stratton VA Medical Center)

Individuals with stable coronary artery disease, or stable angina, experience chest pain on exertion when narrowed or blocked arteries reduce the supply of oxygen-rich blood to the heart muscle. Current treatment calls for lifestyle changes and optimal medical therapy that includes aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers, and statins.

Many patients are also treated through percutaneous coronary interventions (PCIs) because of the belief that opening the narrowed or blocked arteries and placing stents in the treated vessels to help maintain the opening will reduce the risk of death and nonfatal heart attacks. Studies have demonstrated that PCIs help in this manner when used in patients who experience a heart attack or develop unstable angina (which occurs suddenly, frequently with minimal or no exertion).

But recent studies have shot down the idea that PCIs plus optimal medical therapy improve outcomes compared with optimal medical therapy alone in patients with stable coronary disease. Indeed, a meta-analysis appearing today in the Archives of Internal Medicine also concludes stent implantation shows no evidence of benefit compared with initial medical therapy for these patients.

In an accompanying commentary, William E. Boden, MD, describes what will it take to get physicians to change their practice patterns to use PCIs only when appropriate.

Boden, of the Samuel S. Stratton VA Medical Center in Albany, NY, coauthor of the 2007 COURAGE study that first showed the lack of benefit of stenting over optimal medical therapy for treatment of stable coronary artery disease, discusses his commentary:

“What’s amazing to me is that almost 5 years after the original publication of COURAGE, the message is not getting through. We need to somehow find a way to change the thinking among many practicing cardiologists who are infused with the belief that if you don’t offer PCI with optimal medical therapy, you somehow are offering patients inferior care. The evidence simply does not support that belief.

“All of us in medicine, in any specialty, come to do whatever we do with inherent biases and opinions of what we think is best or not best. And when a study comes forward that challenges conventional wisdom, many of us experience an almost counterrevolution of opinion that basically tries to reject or explain away the findings.

“To a large degree, the continued use of PCI in patients with stable coronary artery disease is industry driven, and it’s been driven by our payer system. Payers reward hospitals and physicians who engage in interventional cardiology. More and more hospitals are trying to get into the game because they recognize they get paid more to do PCI than not to do PCI.

“There is also this public perception driving PCI use. Cardiologists are often viewed as action heroes, and the more aggressive you are, the better a physician you are in many patients’ eyes. Also, patients who get referred to a tertiary hospital with the express purpose for getting a PCI and leave with 5 prescriptions instead of the PCI feel like they have somehow not participated fully in the complete spectrum of what technology has to offer. There is an unfortunate feeling that aggressive interventional treatment equals quality, and that if you don’t provide such treatment you are judged in a pejorative fashion.

“The public is not getting clear and unbiased information to sort out the risk and benefits of the different treatment options.”

Categories: Cardiovascular Disease/Myocardial Infarction, Cardiovascular Interventions, Comparative Effectiveness, Drug Therapy, Evidence-Based Medicine