As a surgeon, Dullum prefers to work on people who have not had a stent. “Stents and balloons tend to be destructive because they damage the artery. When it comes time for surgery, we would prefer working on undamaged tissue. Also, a stent can present an obstacle we have to work around,” she says.
What COURAGE explored
One study showed 75% of people believed angioplasty would prevent them from having a heart attack. Was that true? Did they need angioplasty if already on medications?
COURAGE divided its 2,287 participants into two groups. “The medical therapy group received counseling for weight loss, quitting smoking, improving nutrition, and increasing physical activity levels. And we added medications: low-dose aspirin, a cholesterol-lowering drug, and usually a beta blocker and an ACE inhibitor,” says David Maron, M.D., a cardiologist at Vanderbilt University Medical Center who was also one of COURAGE’s coauthors. “The angioplasty group received the same lifestyle and medication therapy. In addition, they underwent angioplasties,” he adds.
Over seven years the doctors compared the incidence of heart attack and death in each group and there was no difference. “The angioplasty group had slightly less angina for the first three years, but by year five, 74% of those who had angioplasty had no angina, compared with 72% in the medical group,” Maron says.
So why have angioplasty?
Since medications work throughout the body and don’t risk scarring, the results seemed to suggest that from here on doctors should avoid angioplasty. But like most things in medicine, there is little about COURAGE that’s black and white. participants all had stable angina. If your angina isn’t stable, this result doesn’t apply to you. Also, 85% of COURAGE participants were men, so we don’t know how well the results apply to women,” Leonard says.
“People see this study and ask, ‘Why shouldn’t I be on these medications? ‘I might have to say, ‘You are already on six medications and these will interact,’” says Tom Morris, D.O, an Erickson Health physician at Monarch Landing, an Erickson-built and -managed community in Illinois. Morris points out multiple medications aren’t unusual in older adults.
Maron agrees COURAGE doesn’t mean there is never a need for angioplasty. “If someone is in the middle of a heart attack, angioplasty clearly has been shown to be beneficial. You need to get that artery open,” he says. “How do you know if your angina will still stay stable? In COURAGE, about one-third of the medication population eventually needed angioplasty,” Leonard says.
Setting the right goals for you
COURAGE doctors used guidelines established by leading health organizations to define success. “We aimed for an LDL cholesterol of less than 70, blood pressure of 130/85, and for diabetes, an A1C level less than 7%,” Maron says.
But not everyone—especially an older population—should realistically expect to meet those goals, particularly if you can’t maintain the strict COURAGE regimen. “The numbers are guidelines. I always like to say we are treating people, not lab results,” says Morris, whose patients are mostly over age 75.
“What works for a 50- and an 80-year-old aren’t the same. The 130/85 guideline for blood pressure (BP), for example, is great. But I have a couple of people in their 80s who can’t achieve it. When I try to get the upper number on their pressure much under 140, they experience dizziness and other problems. You need to look at individualities,” he adds.
“People should ask, ‘What should my BP and LDL be. What should my A1C be if I have diabetes? What’s the best diet and exercise plan for me? Are these doses of medications right for me? Do I need angioplasty?’” Maron says.
“Remember we aren’t saying if you have stents you will never need medication or vice versa. Hopefully people have built good relationships with their physicians, allowing them to ask questions about reports on studies like COURAGE,” Leonard says.