Angina treatment: Stents, drugs, lifestyle changes — What's best?

Angina treatment often involves using stents to widen blocked heart arteries. A study, the COURAGE trial, questions whether angioplasty and stents are necessary. A Mayo Clinic specialist discusses the findings.

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.

What did you and your colleagues discover when you compared those who received stents, took medication and made lifestyle changes with those who only took medication and made lifestyle changes?

We found that in people with chronic stable angina, getting a stent didn't improve their chances of preventing a heart attack or dying. In other words, getting an angioplasty and stent combined with taking medication and making lifestyle changes didn't prevent any additional deaths or heart attacks compared with only taking medication and making lifestyle changes.

When we say "medications" and "lifestyle changes" we mean eating a healthy diet, getting exercise four to five times a week, and taking medications such as statins, anti-clotting drugs like aspirin and high blood pressure medications like angiotensin-converting enzyme (ACE) inhibitors and beta blockers.

Our research suggests that if you have chronic stable angina, you may not need angioplasty and stenting immediately. It may be just as effective to try drug treatment and adopt a healthy lifestyle and diet.

We did discover that people who had angioplasty and stenting initially had earlier and better symptom relief, such as reduced chest pain, than those who just got medication. However, five years later the symptom relief was about the same between the groups. That's worth noting because it's often been argued that stents provide better relief of chest pain. We found that while that's true early on, over time there was no significant difference in relief of symptoms such as chest pain.

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.

Are those with chronic stable angina commonly treated with angioplasty and stent placement right now?

They often are. Though the American Heart Association already recommends people with chronic stable angina first try medical therapy, the practice in many doctors' offices and hospitals has been to first try stents. In fact, about half of all angioplasty procedures are done in people with stable angina. We're saying that, based on our results, angioplasty and stenting may not be necessary in this group of people.

If you have stable angina, you may have just as much success treating it with medical therapy alone — drug treatment and diet and lifestyle changes — and may not need to undergo angioplasty with stenting. If you try drug treatment and lifestyle changes and you still have symptoms that are limiting you, a stent may be the next step. Our results suggest it might be reasonable to try more-conservative steps first — medication and lifestyle therapy for a year or so — before considering a stent.

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.

Drug treatment and some lifestyle changes sound pretty easy.

Make no mistake, what we're suggesting isn't easy to achieve. This is not just as simple as taking a pill. This is intensive medical therapy. For example, when we say you should take statins to reduce your cholesterol, we mean it.

Right now, the average American has a low-density lipoprotein, (LDL, or "bad") cholesterol of around 130. But to achieve the sort of results we saw in our study, you need to get your LDL to about half that — around 60 to 70. You also have to exercise regularly, at least five out of seven days of the week. You also have to maintain a healthy weight, eat a healthy diet and keep your blood pressure down.

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.

What if you already have a stent?

You still need to be on intensive medical management to treat remaining coronary artery disease and diseased arteries (atherosclerosis) elsewhere in your body.

However, if you've had a stent implanted and need future medical treatment for your clogged arteries, you'll likely need additional stents implanted. You won't be able to rely on medical therapy, such as drugs, alone as treatment. This is because if any future problems, such as blockages or clots, do recur they will likely happen near where your stent was implanted. Doctors will then have to insert one or more stents near those old stent sites to correct the problem.

Stents are still safe, and we still recommend stents for those with unstable angina. Though there's been some recent attention on the risk of blood clots forming with some drug-eluting stents, this risk is still quite small.

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.

Were there any limitations to this study?

Like many studies, the COURAGE trial was made up mostly of males (85 percent), and there were few minorities (14 percent). This makes it harder to generalize our results for everyone. Another issue some may point out was our study used primarily bare-metal stents, not the more recent and increasingly common drug-eluting stents. However, there's been no significant difference found between bare-metal stents and drug-eluting stents for preventing death or heart attack. So our using primarily bare-metal stents shouldn't have much impact on our results.

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