Landmark research that should have changed the way doctors treat millions of heart patients with clogged arteries has had little effect — many still don’t first try medicines that sometimes eliminate the need for costly, invasive procedures, a study suggests.
The 2007 research — front-page news when it was published — showed that intensive drug treatment in non- emergency patients with chest pain worked as well as angioplasty in preventing heart attacks, improving survival and relieving discomfort in the long run.
To measure the re- search’s impact, the new study evaluated data on nearly half a million U.S. patients with artery blockages but stable disease treated between 2005 and mid- 2009. Two-thirds had chest pain and all eventually got artery-opening stents during an angioplasty.
Before the landmark findings, fewer than half the patients received drug treatment first, then an angioplasty. In the two years after the study, there was only a tiny increase in patients given drug treatment first — to about 45 percent.
The earlier research suggests many of those given drugs first wouldn’t need an eventual angioplasty, said Dr. William B. Borden, author of the new study and a cardiologist at New York- Presbyterian Hospital/Weill Cornell Medical Center.
He said the 2007 results also show all patients should get drug treatment after an angioplasty to help prevent heart attacks. In his follow-up study, that number increased slightly, but still, almost one-third were not given recommended medication after their angioplasties.
Dr. William Boden of Buffalo General Hospital, who led the 2007 study, said the new results aren’t surprising because it takes time for doctors to change practice. The landmark study’s recommendations will be included in new treatment guidelines due out this year, said American Heart Association spokesman Dr. Sidney Smith. He said that should influence more doctors to use the drug approach first.
The new study was published in the Journal of the American Medical Association .
The drugs it evaluated — aspirin, beta blockers and statins — improve artery health and reduce chest pain. They’re available as generics and cost much less than angioplasties.
Angioplasties do the same thing. Doctors guide a narrow tube through a blood vessel near the groin up toward the heart, inflate a tiny balloon to flatten blockages, and insert a stent to keep arteries propped open. The procedure costs about $20,000, based on average Medicare reimbursement for doctor and hospital fees, and generally requires an overnight hospital stay, said Dr. Sanjay Kaul, a Los Angeles cardiologist.
About 1 million angioplasties are done each year nationwide — half of them in patients with stable heart disease. While recent signs indicate that angioplasty use is decreasing, the new study results suggest not nearly enough heart patients are being given appropriate drug treatment instead.
Kaul estimates that of the $10 billion spent nationwide on these procedures each year in stable patients, more than $2 billion could be saved if drug treatment were tried first, and angioplasties performed only if that didn’t work.
The $33.5 million landmark study challenged conventional thinking on the value of heart stents. Study leader Boden said there are many reasons why doctors and patients may resist the drug approach.
“People feel it’s too timeconsuming, it’s too labor intensive,” Boden said. “Patients say, ‘I don’t like to take meds, let me have a stent.”
They see angioplasties as a shortcut, he said.
Kaul said doctors may fear being sued if they don’t perform angioplasties and patients on drug treatment have heart attacks or die.
And Kaul said patients often prefer angioplasties as a high-tech approach. He said it’s common for angioplasty patients to embrace their doctors afterward and say, “’He went in and fixed it and saved my life.’”
“ I never get a Lipitor hug,” Kaul said, referring to a brand-name statin often used in the drug approach. “It will take a lot of factors to change this mindset.”
Dr. David Holmes, American College of Cardiology president, said the landmark research involved an ideal scientific setting where patients were carefully monitored, but the new study presents a more “real world” view.
Ideally, all heart patients would exercise every day, maintain a healthy weight, avoid smoking and stress — and take all their medicines, every day.
It’s a challenge, Holmes said, but “Is it still reasonable to try? Absolutely.”