# Drugs may be just as good as surgery for clogged arteries



## Carol (Mar 26, 2007)

Interesting article from Monday's _Boston Globe_:



> Patients with clogged arteries who have not yet had a heart attack benefit just as much from medications as angioplasty, according to a study released today.





> Half of the patients took medication and underwent angioplasty, a procedure...The other half received only medication...After tracking the patients for an average of four-and-a-half years, in a trial nicknamed COURAGE, the team, including some scientists from Connecticut, found that there was no difference in outcomes between the groups.


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## Steel Tiger (Mar 27, 2007)

But doctors won't make anywhere near enough money if they only give people drugs.


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## Hand Sword (Mar 27, 2007)

Carol, which drugs were given?


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## Carol (Mar 27, 2007)

It didn't say which specific meds were used, only...



> ...including drugs to lower cholesterol, relax blood vessels, slow heart rate, and prevent blood clots.



The article did mention that the findings would be published in the NE Journal of Medicine...I'm sure that will have more details.

And I'm sure the Pharma companies will let us know at ever turn, given how they advertise


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## Bob Hubbard (Mar 27, 2007)

http://www.msnbc.msn.com/id/17800298/


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## Steel Tiger (Mar 27, 2007)

This really is a seriously good finding.  The less often people have to go under the knife the better.  Interesting collection of drugs.  I wonder which of them was the most effective?  Given the nature of the illness one would naturally assume the anti-cholesterol would be most effective, but that might not be the case.  It will be interesting to see if this can be refined at all.


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## Empty Hands (Mar 27, 2007)

Carol Kaur said:


> It didn't say which specific meds were used, only...
> ...including drugs to lower cholesterol, relax blood vessels, slow heart rate, and prevent blood clots.



Those would probably be statins (like Lipitor) for the cholesterol, beta-blockers (like Carvedilol) for the pressure and heart rate, and aspirin or something similar to prevent clots.  This is not an uncommon cocktail to put someone on who is in danger of a heart attack.

It is also no great surprise that people who haven't had a heart attack yet get no benefit from angioplasty.  After an angioplasty, the vessels quickly grow back the blockage.  Experiments with metal stents to prevent the grow-back have shown to be promising, but they likely weren't used in this study.

Angioplasty is primarily useful in someone who is about to or is having a heart attack.  Restoring blood flow immediately can prevent unnecessary cardiac muscle death.


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## Kenpodoc (Mar 27, 2007)

I get paid the same whether they go to angioplasty or not.  I've not seen the study yet so I can't directly comment on it but in the newspaper the finding was that at five years survival was the same.  In my experience people who get plasty's feel better quickly and many people do not tolerate the meds alone regardless of survival rates.  as physicians we have to balance survival, well being and cost in a very complicated and never clear manner.  If you knew that on $300 a month meds you would be as likely to live 5 years as with a $30000 angioplasty but that the meds would make you tired and grouchy which choice would you make.  the nice thing about this study if true is that it will remove one more opportunity for people to sue me for their own bad behavior.  the bad thing is that it will be that much harder to get procedures paid for which may significantly enhance the quality of life but not the quantity of life.

Jeff


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## Steel Tiger (Mar 27, 2007)

Kenpodoc said:


> I get paid the same whether they go to angioplasty or not. I've not seen the study yet so I can't directly comment on it but in the newspaper the finding was that at five years survival was the same. In my experience people who get plasty's feel better quickly and many people do not tolerate the meds alone regardless of survival rates. as physicians we have to balance survival, well being and cost in a very complicated and never clear manner. If you knew that on $300 a month meds you would be as likely to live 5 years as with a $30000 angioplasty but that the meds would make you tired and grouchy which choice would you make. the nice thing about this study if true is that it will remove one more opportunity for people to sue me for their own bad behavior. the bad thing is that it will be that much harder to get procedures paid for which may significantly enhance the quality of life but not the quantity of life.
> 
> Jeff


 
It is an important and interesting point you make about the tolerance of the drugs.  There was no mention made in the article of this side of the study.

I think, given the number you quote, that a lot of people would have to settle for tired and grouchy for five years because of what they can afford ($18000 versus $30000).


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## donna (Mar 27, 2007)

One point that needs emphasising is that the study was carried out on *Stable, Non Emergency patients*. In the case of an emergency patient the surgery was still often the best course of action.


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## Steel Tiger (Mar 27, 2007)

donna said:


> One point that needs emphasising is that the study was carried out on *Stable, Non Emergency patients*. In the case of an emergency patient the surgery was still often the best course of action.


 
That's true.  Can't argue with that.


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## jdinca (Mar 27, 2007)

I think the study raises more questions than it answers. Yes, nonemergent patients with blockage did just as good with medication as with angioplasty, yet those who went through the procedure had a slightly better quality of life because of the reduction of episodes of angina. The medications used to combat/prevent blockage can also have side effects that have a definite impact on the quality of your life, not to mention the patient may not be able to tolerate the medication itself. They can also need adjustments in dosage on a frequent basis based on the condition of the patient, especially if there are multiple pills being taken. 

I think in the near term the companies that make stents are going to take it in the shorts. In the long run, it's given them impetus to put more into research and come up with a better mousetrap.


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## Carol (Mar 27, 2007)

jdinca said:


> I think the study raises more questions than it answers. Yes, nonemergent patients with blockage did just as good with medication as with angioplasty, yet those who went through the procedure had a slightly better quality of life because of the reduction of episodes of angina. The medications used to combat/prevent blockage can also have side effects that have a definite impact on the quality of your life, not to mention the patient may not be able to tolerate the medication itself. They can also need adjustments in dosage on a frequent basis based on the condition of the patient, especially if there are multiple pills being taken.
> 
> I think in the near term the companies that make stents are going to take it in the shorts. In the long run, it's given them impetus to put more into research and come up with a better mousetrap.



Yep.  The globe announced Boston Scientific's stock took a hit the day the news was announced.   They make stents and other biomedical devices.


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## Kenpodoc (Mar 27, 2007)

Steel Tiger said:


> It is an important and interesting point you make about the tolerance of the drugs. There was no mention made in the article of this side of the study.
> 
> I think, given the number you quote, that a lot of people would have to settle for tired and grouchy for five years because of what they can afford ($18000 versus $30000).


Possibly but of course insurance tends to pay better for procedures than med.  Also many people given the choice of say 5 good years with sudden death and 10 bad years would choose the five good years.  it's these differences that make medical choices so hard and so easy to second guess.  these choices also make the studies tougher to evaluate than the popular press would indicate.

Jeff


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## Kenpodoc (Mar 27, 2007)

jdinca said:


> I think the study raises more questions than it answers. Yes, nonemergent patients with blockage did just as good with medication as with angioplasty, yet those who went through the procedure had a slightly better quality of life because of the reduction of episodes of angina. The medications used to combat/prevent blockage can also have side effects that have a definite impact on the quality of your life, not to mention the patient may not be able to tolerate the medication itself. They can also need adjustments in dosage on a frequent basis based on the condition of the patient, especially if there are multiple pills being taken.
> 
> I think in the near term the companies that make stents are going to take it in the shorts. In the long run, it's given them impetus to put more into research and come up with a better mousetrap.


Now if and when they can come up with a vascular growth factor that speeds collateral vessels and self bypasses.  I'm not against medical treatment, I've cared for quite a few "inoperable people" who we stablized and after several years with modifies risk factors (increase exercise, no tobacco, less McDonalds, fewer chips, regain some joy in life) regained coronary circulation.  Now if only I knew which people would  do this and which needed intervention in advance I'd be a super doctor.

Jeff


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