For years, cardiologists have been arguing over the best way to treat people who have stable angina. Stable angina is chest discomfort, due to coronary artery disease, that occurs only under conditions such as exercise or other stresses that require the heart to work harder.
Most cardiologists have long favored the "invasive" approach to treating stable angina, that is, treating it with angioplasty and stenting or bypass surgery. However, other cardiologists have argued that treating stable angina with medicines and other non-invasive treatments works just as well.
In 2007, the COURAGE trial showed that patients with stable angina had similar outcomes (that is, a similar risk of heart attack or death) whether they were treated with aggressive medical therapy or with stents.
But even with these results, many cardiologists continued to argue that because patients probably have a better quality of life (QOL) after invasive therapy than they do with only medical therapy, so invasive therapy is still to be preferred.
This QOL argument was undermined when an analysis was published in the New England Journal of Medicine using QOL data from the COURAGE trial. This analysis showed that QOL was substantially improved whether patients received stenting or medical therapy. While gains in QOL were somewhat higher with stenting than with medical treatment, that difference lasted for only a year or two. By year three, QOL was the same in both groups.
Proponents of the invasive treatment of stable angina are still not entirely convinced, however. They point out that drug-eluting stents (DES) were not used in the COURAGE trial, so restenosis may have been more frequent. They also note that, in the real world, many doctors fail to use optimal medical therapy in their patients with stable angina.
Their less invasive-minded colleagues counter that DES create their own special and often difficult problems. Furthermore, they say, it hardly seems a legitimate argument for cardiologists to default to stenting because they themselves would otherwise fail to deliver optimal medical therapy.
The Bottom Line
The QOL analysis from the COURAGE trial supports the initial conclusions of the study as reported in 2007. Stenting did not offer any improvement in survival or heart attack prevention as compared to optimal medical therapy, and any differences in QOL outcomes between the two forms of therapy were temporary.What This Means to You
If you have stable angina, make sure your cardiologist discusses all the evidence with you before recommending a course of action. In most patients with stable angina, it would be quite reasonable to try optimal medical therapy as the first step. If optimal medical therapy fails to adequately control symptoms, then stenting could be offered as a second step. Such a strategy seems to result in similar cardiac outcomes as an "invasive therapy first" strategy, and it offers a chance to avoid some of the pitfalls of more invasive treatments.In any case, since the outcomes appear quite similar with either approach, this is one situation where your own opinions about which type of medical therapy you would prefer should carry a lot of weight.
Sources:
Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356:1503-16.
Weintraub WS, Spertus JA, Kolm P, et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med 2008; 359:677-687.
