Angioplasty has No Benefit Over Medical Therapy in Ischemic Stable CAD

 

A new analysis is calling into question the rationale for many of the angioplasty procedures taking place today in patients with stable coronary artery disease (CAD). In a meta-analysis of more than 5000 patients, Angioplasty was no better than medical therapy in patients with documented ischemia.

Its routine in cardiology practice to advise angioplasty or revascularization if stress test is positive. Patients with ischemia have a worse prognosis than patients who don’t. Thus cardiology practice is focused on finding and treating ischemia. However, the analysis of this study suggests that this approach may not be the right one.

 

Brown and colleagues reviewed the literature for clinical trials of angioplasty and medical therapy for stable CAD conducted over the past 40 years, ultimately including five trials of 5286 patients. These were a small German trial published in 2004, plus MASS II , COURAGE , BARI 2D , and FAME 2 . In all, 4064 patients had myocardial ischemia documented by exercise, nuclear or echo stress imaging, or FFR.

Over a median follow-up of five years, mortality, nonfatal MI, unplanned revascularization, and angina were no different between patients treated medically vs those treated with Angioplasty.

The analysis suggests that it may be worthwhile to continue medical therapy in patients with minimal symptoms and not subject them to unnecessary intervention.

 

via PCI No Benefit Over Medical Therapy in Ischemic Stable CAD.

Docs Not Giving Best Post-MI Prevention Care?

Its a worrying finding for patients.

A significant percentage of patients with coronary artery disease (CAD) still aren’t being prescribed the recommended secondary prevention drugs that could save their lives, a new analysis confirmed.

About a third of CAD patients enrolled in a national registry were not taking a combination of beta-blockers, statins, and ACE inhibitors/angiotensin receptor blockers (ACEI/ARBs) after having a heart attack or undergoing percutaneous coronary intervention (Angioplasty/ PCI) or coronary artery bypass grafting (CABG/ bypass surgery).

And compliance with the secondary prevention drug recommendations varied greatly from practice to practice, researcher Thomas M. Maddox, MD, of the VA Eastern Colorado Health Care System in Denver, and colleagues, wrote online Oct. 30 in the Journal of the American College of Cardiology.

 

The researchers examined data from the American College of Cardiology’s PINNACLE Registry, which is the first national, prospective, outpatient-based cardiac quality improvement registry of patients being treated in cardiology practices in the U.S.

Patients treated at 58 PINNACLE practices between July of 2008 and December of 2010 were included in the analysis.

Among 156,145 coronary artery disease (CAD) patients treated at 58 participating practices, 66.5% were taking beta-blockers, statins, and ACE inhibitors/angiotensin receptor blockers on their first post-event visit, and only slightly more (69.7%) had been prescribed these recommended medications a year later.

 

This is worrying that one-third of the patients are not getting the necessary drugs to  prolong survival.  This is despite the fact that most of the doctors have now access to latest medical information and guidelines due to availability of smart phones and internet access. If this is the situation in the western world, it would be worse in the developing countries.

In an editorial published with the analysis, L. Kristin Newby, MD, of Duke University, wrote that efforts to increase the use of optimal drugs for secondary prevention should focus not only on cardiologists but also family practice physicians, internists, gynecologists, and advanced practice providers such as nurse practitioners and physician’s assistants.

 

via Docs Not Giving Best Post-MI Prevention Care?.

Bypass surgery (CABG) beats Angioplasty (PCI) in diabetic patients

 

Patients with diabetes and multivessel coronary artery disease treated with Bypass surgery (CABG surgery) had significantly lower rates of death from any cause, nonfatal MI, or nonfatal stroke when compared with diabetic patients treated with PCI (Angioplasty and stenting), according to the long-awaited main results of the FREEDOM trial. The study was presented in the AHA meeting in 2012 and published subsequently in the NEJM. It studied 1900 diabetic patients, majority with triple vessel disease and found that surgery was a superior option compared to angioplasty.

 

The study concluded that in diabetic patients with complex disease, “CABG was of significant benefit as compared with PCI.”  CABG was also associated with a significant reduction in the risk of heart attacks and all-cause mortality, while PCI was associated with a lower risk of stroke. For the FREEDOM investigators, CABG surgery should be the preferred method of revascularization for patients with diabetes and multivessel coronary artery disease.

There have been trends showing similar results recently (in Feb 2013) too in a smaller study, called VA-CARDS following up 198 patients. The study was published in the JACC journal and again proved that Diabetic patients with multivessel disease would be better off with surgery. 

Considering the evidence the debate over PCI vs CABG in diabetic patients should end now, given the clear results from FREEDOM. These new data highlight the importance of collaboration and cooperation between the Cardiologists and Surgeons to provide the best patient care. The data also clearly show that for patients with diabetes and multivessel disease, “surgery is the best option for patients,” a finding that has important implications given the obesity epidemic and rising rates of diabetes in the developed world.

via CABG beats PCI in diabetic patients | theheart.org.

Treatment for Acute Stroke: Clot buster or Angioplasty?

There are 2 treatment options for patients suffering from acute stroke. One is a clot buster called t-PA which is given intravenously. The second is a procedure called Angioplasty wherein the blocked artery is opened mechanically by a clot aspirating device or giving the drug directly into the artery with the help of small tubes. In some cases, a stent (spring like device) is placed across the artery.

There has been a long standing debate to know which one is a superior treatment option. Physicians consider the Angioplasty option as superior as the doctor is directly opening the artery by a mechanical device. The drug option is considered inferior as the effect of the drug can be limited in some patients.

So for the first time, both these treatment options were compared directly with each other. They found that the Clot buster was more effective when compared to the angioplasty approach. The study got published in the NEJM, a premier medical journal in the Feb 6, 2013 issue.

362 patients with acute ischemic stroke underwent randomization (181 to endovascular treatment and 181 to drug-tPA). Primary outcome of death and disability was studied at the end of 90 days.

A total of 55 of the 181 patients (30.4%) in the endovascular-treatment group survived without disability as compared with 63 of the 181 patients (34.8%) in the intravenous t-PA, drug group (absolute difference, −4.4 percentage points).

At 90 days, 26 patients in the endovascular-treatment group (14.4%) and 18 in the intravenous t-PA group (9.9%) had died.

This trial failed to show that the Angioplasty approach was superior to the drug option: intravenous t-PA. It also challenged the Physicians common notion that Angioplasty is superior to the drug.

It is a victory of a Drug over a mechanical procedure called Angioplasty. Again, reminding us that with the advent of better drugs, equally good and sometimes more effective treatment can be delivered safely!