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Study Shows Patients Are Missing Out on Benefits of Preventive Medications
By Salynn Boyles
WebMD Health News
Reviewed by Laura J. Martin, MD
The study is published in TheJournal of the American Medical Association.
Less than half of the heart patients in the study with stable disease were taking antiplatelet drugs, statins, and beta-blockers before receiving stents or balloon angioplasty to open clogged blood vessels.
About a third of the patients weren't prescribed the drugs after having the procedures.
Researchers found little difference in use of the drugs before and after the publication of a landmark 2007 study, known as COURAGE, which found that stents and angioplasty offered no survival advantage over preventive drug treatments alone in patients with stable coronary artery disease.
The study demonstrated the value of optimal drug management in these patients with a low risk for heart attacks and death. But its impact on clinical practice has been minimal, study researcher William B. Borden, MD, of Cornell University's Weill Cornell Medical College, tells WebMD.
"When COURAGE was published it received a great deal of coverage in the medical and public press, so it was surprising to find that it did not influence practice patterns much," Borden tells WebMD.
Drug Treatments: 'Room for Improvement'
Borden and colleagues analyzed data from a national registry of patients with stable coronary artery disease treated with stents or balloon angioplasty between September 2005 and June 2009.
The analysis compared treatment with aspirin or another antiplatelet drug, beta-blockers, and cholesterol-lowering statins before and after the publication of the COURAGE trial and before and after hospital discharge following the percutaneous coronary intervention (PCI) procedures stenting or angioplasty.
Just over a third (37%) of the more than 460,000 patients included in the analysis were treated with PCI procedures before the COURAGE findings were made public.
Prior to the trial's publication, around 43% of patients were on the drugs before having the interventional treatments. After its publication, around 45% of patients were taking the drugs before PCI.
After undergoing an interventional treatment, about 63% of patients were prescribed the drugs pre-COURAGE, compared to 66% of patients after the study's publication.
"These findings suggest a significant opportunity for improvement and a limited effect of an expensive, highly publicized clinical trial on routine clinical practice," Borden and colleagues write.
Drug Therapy Before and After Stents
Research comparing the impact of different treatments on outcomes in specific patient groups is a major focus of the health care reform bill signed into law by President Obama last year.
Borden says a major message to policy makers as they fund studies comparing different treatments is that they also need to find better ways to implement findings from these comparative studies.
"One of the real lessons here is that we need to focus more on making sure that the findings from research studies like this one actually make it to clinical practice," he says.
American Heart Association president-elect Gordon F. Tomaselli, MD, tells WebMD that preventive drug treatments are being underprescribed to patients with stable coronary artery disease.
Tomaselli, who directs the division of cardiology at the Johns Hopkins University School of Medicine in Baltimore, says it is of particular concern that roughly a third of patients in the study were not prescribed the drugs after treatment with stents or angioplasty.
He adds that the patients included in the COURAGE trial with stable coronary disease make up a minority of patients with heart disease.
Benefits of Drugs and Heart Procedures
While the benefits of stents and angioplasty beyond improvement in chest pain symptoms are not clear for these patients, this is not true for patients with less stable, more advanced disease, he says.
"There are clearly people who have better outcomes with these interventions, and we know who they are," he says. "They are patients with acute myocardial infarction, ST segment elevation, and other signs of ongoing [heart] muscle injury."
Interventional cardiologist Barry Kaplan, MD, points out that these patients also benefit from the drug treatments, but many clinicians fail to recognize this.
Kaplan is vice chairman of cardiology at North Shore University Hospital in Manhasset, N.Y.
"Many clinicians think of PCI as a standalone treatment, which is a big misconception," he says. "The idea that if you fix the blockage, medical treatments are less important couldn't be more wrong. Fixing the blockage does not negate the responsibility to be vigilant about the need for optimal medical therapy."