The controversy surrounding the proper treatment of stable heart disease was highlighted some years ago, when former President George W. Bush decided to have a stent placed, even though he had not had a heart attack and was not experiencing angina (chest pain caused by restricted blood flow to the heart). During an annual exam, his stress test showed an abnormality; then an angiography showed a blockage, and President Bush and his physicians decided to proceed with stenting. Of course, we don’t know all the details of President Bush’s condition, but the situation brings to light an important issue in healthcare in the U.S.: having a stent placed in the absence of symptoms is common in the U.S., but is it good medicine or malpractice?
This was investigated in the COURAGE trial — a large and important study published in 2007, whose conclusion was that angioplasty and stent procedures (percutaneous coronary interventions or PCI) did not offer any survival advantage over medications alone. After five years of follow-up, the group of patients receiving PCI did not have fewer heart attacks or cardiac deaths than the group who received optimal medical therapy (OMT; modest lifestyle changes plus anti-platelet, blood pressure-lowering, and cholesterol-lowering medications).[1]
