It's practically gospel in American health care--the more expensive and the more invasive a treatment is, the more people seem to believe it is the best option. But is it? A new study looks at America's number 1 killer -- heart disease -- and finds that a regimen of fairly inexpensive pills works just as well as an expensive surgical procedure to implant a stent. Oh, and drug treatment has fewer risks in this case, too.
The study is published in this week's Archives of Internal Medicine and it looks at stable coronary artery disease. In stable heart disease, patients experience angina --chest pain -- at times of "high demand" such as during exercise or stress.
This study is a new review of a group of randomized trials which had compared medication treatment with the surgical option, called percutaneous coronary intervention, or PCI. In PCI, a surgeon threads a narrow tube through an artery to a point where there is blockage in the heart and inserts a stent--a mesh tube--against the walls of the artery to hold it open.
While it certainly sounds like a good idea, researchers found no benefit over drug therapy. As the authors write:
The significant finding of this analysis is that compared with a strategy of initial medical therapy alone, coronary stent implantation in combination with medical therapy for stable CAD [coronary artery disease] is not associated with a significant reduction in mortality, nonfatal MI ... or angina.
"MI" is shorthand for myocardial infarction--a heart attack. So, in other words, if you have stable heart disease, you will do just as well with the less expensive pills and you will not bear the risks of surgery. But PCI is a popular procedure. The researchers report that more than 400,000 Americans a year have PCI with a stent implanted every year.
The New York Times took a detailed look at this study today and reported that one of the drivers for PCI over medications could be money, The Times reports the cost of PCI ranges from $30,000 to $50,000 and interviewed Dr. David Brown, an author of the study:
More than half of patients with stable coronary artery disease are now implanted with stents without even trying drug treatment, Dr. Brown said. The reason, he believes, is financial.
“In many hospitals, the cardiac service line generates 40 percent of the total hospital revenue, so there’s incredible pressure to do more procedures,” he said.
“When you put in a stent, everyone is happy — the hospital is making more money, the doctor is making more money — everybody is happier except the health care system as a whole, which is paying more money for no better results.”
The study reviewed 7,229 patients who had a been enrolled in eight different trials. Of those patients, 3,617 received stents and medication while 3,612 received just the medications. There were 649 total deaths during the trials, 322 in the stent group and 327 in the medication group. Some doctors argued that certain patients do not tolerate the drugs well and they could still be candidates for PCI and stent treatment.
In an accompanying editorial in the Archives, Dr. William Boden writes about doctors who outwardly "worship at the altar of evidence-based medicine" as long as studies or trials reinforce what they already believe, "while we ignore or disdain the results of studies with results that are unpopular ... or collide with the conventional wisdom."
And where does this collision with conventional wisdom leave the patient? The Times concludes with an explanation of the current understanding of heart disease. Patients, take heed:
These results support the current concept of coronary artery disease, the authors wrote — that it is a systemic inflammatory disease of the arteries that cannot be successfully treated by surgical intervention at a particular site on one artery.
According to Dr. Brown, a professor of medicine at Stony Brook University, many doctors cannot accept this. Instead, he said, “interventional cardiologists use the analogy of a pipe blocked in a house — it’s a terrible analogy, but patients accept it. It’s simplistic and erroneous.”