"COURAGE" Not Enough: A Million Stents A Year

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Terrific piece in the Wall Street Journal headlined, “A Simple Health Care Fix Fizzles Out.”

It documents how the “blockbuster” COURAGE trial three years ago that questioned the effectiveness of “the most common heart surgery” – coronary artery stent placement – had a brief impact on clinical practice but “as the headlines faded,” stentings soon began to rise again.

P1-AT764_COMPAR_NS_20100210211756-1.gifThe graph at left is from the WSJ piece, showing that stenting “is now back at peak levels of about one million a year.” Excerpts from the article:

“Sanjay Kaul, a prominent cardiologist and researcher at Cedars-Sinai Heart Institute in Los Angeles, estimates that the U.S. could save $5 billion of the $15 billion it spends on stent procedures each year if all doctors followed Courage’s guidance–that is, putting certain heart patients on generic drugs and turning to stents only if the pains persists. …

Ajay Kirtane, a cardiologist at Columbia University, believes that American expectations about medical “fixes” makes it hard to follow recommendations such as Courage’s. If a doctor attempted to persuade a patient to delay stenting in order to see whether drug treatment would work by itself, he says, the patient would likely drop him and see another cardiologist instead.”

Read the entire piece. And thanks to the WSJ for still allowing reporters to write 2,000-word articles like this.

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Comments (4)

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Marilyn Mann

February 11, 2010 at 9:32 am

I think part of the problem is that many cardiologists don’t really explain the COURAGE findings to their patients with stable coronary disease. COURAGE found that in this group of patients, stenting in combination with optimal medical therapy does not reduce heart attacks and death compared with optimal medical therapy alone (it does reduce chest pain earlier). In contrast, stenting does save lives in patients who have heart attacks. Consciously or unconsciously, interventional cardiologists often let their patients believe that putting in a stent will prevent them from having a heart attack. This is based on the naive and outmoded idea that coronary artery disease is essentially a plumbing problem and that heart attacks result from areas of severe stenosis (blockage). In reality, most heart attacks result from plaque rupture that occurs in areas with no flow-limiting stenosis. Statins work in part by stabilizing plaque.
Something that hasn’t yet been covered much in the press so far as I know is that there are some interventional cardiologists who advocate trying to identify “vulnerable plaque” (i.e., plaque that is prone to rupture) through imaging and then stent each area of vulnerable plaque. If that crazy idea ever takes off costs will really go through the roof. Steve Nissen wrote a critical editorial on that last year (sub. req.).
J Am Coll Cardiol Img, 2009; 2:483-485, doi:10.1016/j.jcmg.2008.12.015
Nissen, S. E., The Vulnerable Plaque “Hypothesis”: Promise, but Little Progress

Rose Hoban

February 11, 2010 at 4:11 pm

And… whaddya know? CNN is reporting on Thursday afternoon (2/11) that Bill Clinton is getting, you guessed it, 2 stents after ending up in the hospital with chest pain!
Sigh. You’d think the big dogs would read the data… NOT.