Treatment for Coronary Artery Disease Becoming More Effective?

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Submitted by Dr T on May 1, 2014 – 4:45pm

With the Affordable Care Act and other cost-saving pressures being applied over the coming years, how will these innovations continue to improve cardiovascular care – specifically with regards to coronary artery disease?

In the treatment of CAD many studies have shown Optimal Medical Therapy is more effective for patients with stable Coronary Artery Disease, at a fraction of the cost. Interventions should be limited to those at risk (85% of PCI may not be indicated):

In  a January 4th, 2012 JAMA editorial, the authors describe that patients were not being helped by a variety of well-established procedures including stenting for stable coronary artery disease:

“Percutaneous coronary intervention (stenting) performed for stable coronary artery disease… cost(s) billions of dollars and (has supported) the existence of (an) entire specialty for many years. Stable coronary artery disease accounted for 85% of all stenting in the United States at the time of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. Large, well-designed randomized trials that tested whether these practices improved major patient outcomes revealed that patients were not being helped. Defenders of these therapies and interventions wrote rebuttals and editorials and fought for their specialties, but the reality was that the best that could be done was to abandon ship... There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it is possible that some entire medical subspecialties are based on little evidence.

The results of COURAGE have done little to improve optimal medical management of stable coronary artery disease prior to invasive intervention. Stenting may not improve mortality, but the procedure apparently diminishes angina.

CABG remains the standard of care and is by far the more cost-effective in comparison with stents (w/i one year!).

The  editorial is consistient a number of articles we have written for this website, including reviews of the SYNTAX trial and in a letter to to the editor of Wallstreet Journal in 2010.

Patients with stable coronary artery disease (85% of all US patients!) are often recommended to undergo procedures that will not prolong their lives, nor prevent recurrences and thus

  • Face repeat stenting at regular intervals:
    • 10-15% stent failures
    • 40% repeat stent procedures within one year!
    • After one year repeat stent procedures become more expensive than CABG.
  • Need to use expensive medications to prevent stents from repeat blockages

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