Monday, March 16, 2009


It has been hotly debated since 2007, when the COURAGE trial was first announced, that optimal medical therapy is the best for our patients with stable coronary heart disease. But this strategy is very poorly accepted by our local lay-population, who usually sees a blockage almost like a death sentence. When they have chest pains ( not due to a heart attack ), they get investigated, usually with a stress ECG, and now more and more with the 64MSCT. If either of these are positive, they are told that they need a coronary angiogram ( sometimes in the same afternoon, we call this a drive- through angiogram ), and upon seeing a stenosis ( God forbid ), they are told that they need an angioplasty to " clear the blockage " or else they may suffer a heart attack and die. Of course the poor patient ( mildly sedated ) and obviously very frighten, would agree and the interventional cardiologist will happily ( and gleefully ) go ahead to perform an angioplasty, and implant some drug-eluting stents ( sometimes generic, unapproved ones too ), and the patient ends up with a large bill.
Well, is there good medical evidence for that.
The straight-froward answer is NO. In fact the last issue of Lancet ( 14th March 2009 ) carried a large meta-analysis ( >25,000 patients, 61 clinical trials, from 1987-2007 ), by Dr T Trikalinios of Tufts, comparing optimal medical therapy against angioplasty in chronic stable angina pectoris, and found that both therapies were comparable in their longterm outcome. There was no difference in heart attack rates and no difference in survival rates, over 20 years. That angioplasties should be reserved for patients with an acute myocardial infarction, unstable angina or when medical therapy is unable to control the symptoms.
Of course, this is a re-affirmation of the 2007 COURAGE trial by Bill Borden.
Alas this message has still not sunk in. At least not to my knowledge. The local medical community is still exercising, what in our discipline, we call the " Oculo-stenotic " reflex and in fact, I suspect, many " dilate for bread ". After all, the consult fees for medical consultation and medical therapy is RM 100 and the fees for angioplasty procedure is about RM 3-7 K depending on which institution you may go to.
I can only conclude that medicine has become a business.
Patients be aware. If you had stable coronary heart disease, medical therapy is good therapy and the preferred therapy, angioplasty not withstanding.

1 comment:

MBI said...

These are brave honest words from inside the profession. What exactly is stable CHD? I have had two stents in last two years, but always suspected that I was "rushed through" with the procedure. Instead of the ocassional chest pains before the stents, I now have high uric acid, tinkling numbness in hands, frequent reflux, inflammatory sensation.