Angina treatment options include angioplasty and stents. A study, the COURAGE trial, questions that.
Gerald Gau, M.D.
Your doctor says your chest pain (angina) is caused by blockages in your heart arteries and that you need to get those blockages taken care of.
Now what?
Depending on how clogged your arteries are, your doctor may suggest angioplasty and stent placement as an angina treatment option to open up your narrowed arteries and relieve angina. During an angioplasty — also called a percutaneous coronary intervention (PCI) — a tiny balloon is inserted into your narrowed artery. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open.
Angioplasty and stent placement is a common angina treatment strategy. Chronic stable angina is a form of chest pain that happens when your heart is working harder and needs more oxygen, such as during exercise. The pain goes away when you rest. Your narrowed arteries can be the cause of this form of angina.
Many doctors consider angioplasty with stent placement to be a good angina treatment option for blocked arteries and chronic stable angina. That's because it's less invasive than open-heart surgery and has had good results. But a large medical study published in 2007 suggested angioplasty and stent placement might not be necessary to treat many cases of chronic stable angina.
Here's what happened. From 1999 to 2004, 50 medical centers across the United States and Canada, including the Mayo Clinic, agreed to randomly divide 2,287 people with partially blocked coronary arteries and chronic stable angina into two groups. One group had angioplasty with a stent implanted, took medication and adopted healthy lifestyle changes. The other group of people in the study just took medication and made healthy lifestyle changes, but did not have angioplasty and stent placement.
The study was known as the COURAGE trial. COURAGE stands for Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation. The COURAGE trial was formed to find out if combining angioplasty and stents with medication and lifestyle changes was more effective at preventing death or heart attacks than just taking medications and making lifestyle changes alone.
The results of the study surprised many people and caused some controversy among doctors. Gerald Gau, M.D., is a Mayo Clinic specialist in cardiovascular diseases who was involved in the study. Dr. Gau has been involved with the National Cholesterol Education Program Coordinating Committee, which develops national cholesterol guidelines. Dr. Gau discusses the findings of the study.
Do these angina treatment results apply to everyone with a blocked or clogged artery?
No, but they apply to a lot of them. We looked at people who had chronic stable angina. In other words, these were people who had regular, predictable chest pain, due to partially blocked arteries. This is a large group of people. The American Heart Association estimates 400,000 people in the United States are diagnosed with chronic stable angina each year. Our angina treatment results from the COURAGE trial don't apply if you have unstable angina.
Unstable angina is a change in your usual pattern of chest pain. It's chest pain that's getting worse or lasts longer or that doesn't get better with rest or use of nitroglycerin. Unstable angina is dangerous and a warning sign of a heart attack. If your angina is unstable, then urgent medical care, and very possibly angioplasty with stents, is still recommended.
When might angioplasty and stents plus medical therapy be a good angina treatment option for chronic stable angina?
If you try medication and lifestyle changes but they don't relieve angina, angioplasty and stents may be an option. Angioplasty with stenting is still a very appropriate angina treatment option for people with unstable angina. This study only suggested it may not be necessary as initial treatment for many people with chronic stable angina who today often undergo that procedure.
It's also worth pointing out that while percutaneous coronary intervention (PCI) — the procedure of angioplasty and stenting — is quite safe, it still involves some risk. There's a small risk of blockages re-forming after a stent is implanted, as well as additional risks — albeit small. Finally, inserting a stent is expensive, meaning you may want to factor the higher cost into your medical decision.
It does sound challenging. Were the people in this study able to take their medications as directed and stick with a healthy diet and exercise plan?
Yes. Using medication and lifestyle changes alone is challenging, but it does work. I watched angina disappear in those who were involved in this study at Mayo Clinic. You've got to reduce your blood sugar levels if they're too high, maintain a healthy blood pressure and lower your cholesterol. To do this, you have to exercise, eat more fruits and vegetables and lean meats, and take your medications. But if you do all that, your angina and the blockages in your heart arteries can disappear, or be significantly reduced.
This is just one study. So, how should you use these results?
You're right. This is just one study. However, this was the largest study comparing the two treatment options and the results were quite clear. Having said that, as with any medical treatment, you should talk with your doctor about what's the best option for you. These results surprised many doctors and continue to cause a lot of debate in the medical community. So, it may take a while for doctors to come to a consensus on how to use our study results.
Still, it should be emphasized that in our study, the use of stents in someone with stable angina did not prevent death or heart attacks over drug treatment and other medical therapy, and there was no long-term difference in chest pain relief.
Last Updated: 10/24/2007
