Cheap Medicine vs. Expensive Medicine

How to treat chest pain?

At issue is how to treat about 500,000 Americans who each year develop “stable angina,” which is chest pain that occurs in predictable fashion and is caused by blockages in the heart’s coronary arteries. There are two common treatment approaches. One is angioplasty with stenting, in which a catheter is threaded into the narrowed artery, which is then propped open with a tube made of metal mesh. The other is medication and changes to lifestyle.

In many people’s minds, this issue is settled. The answer came in a $33.5 million clinical trial called COURAGE, whose results were announced five years ago. In that experiment, 2,300 people with stable angina were given “optimal medical therapy” consisting of aspirin, beta blockers and statin drugs, along with help losing weight, quitting smoking and keeping blood pressure under control. Half were also randomly assigned to get angioplasty and stenting. (The varieties of the procedure are known collectively as “percutaneous coronary intervention,” or PCI.)

After nearly five years, the rate of heart attack and death in the two groups was essentially the same: 18.5 percent in those getting only medical therapy and 19 percent in those who also got stents. The only difference between the groups was that people getting stents were slightly more likely to be angina-free (66 percent vs. 58 percent after one year).

Predictably, this study has had very little impact on how cardiologists practice, and most of them perform just as many angioplasties for angina as they did before. To get health care costs down in America, a way has to be found to get doctors to stop doing this sort of thing. Americans who think all such decisions should be made by patients and their doctors need to face the numbers.