CDU

In today's microwave society, where results are sometimes wanted yesterday, coronary stent procedures have proven to be an amicable solution for treating diseased arteries. Recovery time is fast - sometimes as quick as three days - compared to the six weeks it would take someone to recover from bypass surgery.

But does this mean that stenting is the better and most efficient option?

A study conducted by the Agency for Healthcare Research and Quality (AHRQ) says no and points out that patients experienced fewer repeat procedures and less angina or chest pain with coronary artery bypass grafting (CABG) surgery than with percutaneous coronary interventions (PCI) and stenting.

The report comes on the heels of the mounting controversy surrounding the usefulness of drug-eluting stents (DES) and could be a blow to the stenting industry as a whole.

"Some cardiologists would say the only reason to have bypass surgery was if stenting had failed. That is completely false," Robert Guyton MD, chief of cardiothoracity at Emory University (Atlanta), told Cardiovascular Device Update. "There is a growing awareness out there that stenting isn't the answer for coronary artery disease. [Stenting] is useful in early and intermediate stages but surely not the advanced stages and [for] handling multiple blockages."

CABG is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, recent research has also shown that this surgery can be done with the heart still beating, by putting stabilizing devices on the heart.

The problem according to Guyton is that stenting fixes one single blockage in a vessel and does nothing to address the remainder of the diseased artery. Bypass surgery, however radical and invasive, addresses broader difficulties of the vasculature.

"In patients with advanced coronary artherosclerosis — generally patients with more than two and certainly patients with more than three major blockages — CABG as initial therapy offers not only the best chance of angina relief and freedom from repeat procedures, but also a substantially better chance of survival at three to five years compared to angioplasty with stents as initial therapy," said John Mayer, MD, president of the Society of Thoracic Surgeons (Chicago). "Because this information is so important, it is critical that both cardiologists and primary care physicians educate their patients so they can help them make informed treatment decisions."

The study, which followed more than 10,000 patients in 23 randomized trials, found that almost 84% of bypass surgery patients were free of angina pain one year after the procedure compared to 75% of patients who underwent the stenting procedure. It also points out that about 24% more angioplasty patients had a repeat procedure within one year compared to those who had bypass surgery.

The study also concluded that quality-of-life scores improved significantly for three years following CABG compared with PCI. The degree of improvement in quality of life was correlated with relief of angina.

So why the turn toward stenting procedures in the face of such good numbers for CABG procedures in the first place? Guyton said the answer is largely patient preference.

"It has to do with everybody wanting a quick, easy fix instead of spending the time to address the entire problem," he said.

"Choosing a treatment for coronary disease has long been a difficult challenge," said AHRQ Director Carolyn Clancy, MD. "But this new evidence-based report provides a vital reference to help doctors, patients and their families make the best possible decision."

CDC study confirms link between COPD and heart disease

WASHINGTON — Device makers know that heart disease is a growing area of concern, and so do members of the American Public Health Association (APHA; Washington), which included a session on the epidemiology of heart disease. One presenter confirmed the long-held suspicion that those who suffer from a well-known and severe lung disease are indeed more likely to have cardiovascular disease.

Joseph Finklestein, MD, a professor of epidemiology at the University of Maryland Medical Center (Baltimore), reviewed the correlation of chronic obstructive pulmonary disorder (COPD) and cardiovascular morbidity. Finklestein noted that COPD "is the fourth leading cause of death in the U.S." and is projected "to be the third leading cause of death by 2020."

However, data suggests that non-respiratory disease accounts for more than half the deaths of COPD patients, and recent studies suggest a link between COPD and cardiovascular disease. He based these remarks on data provided by an annual survey conducted by the Centers for Disease Control and Prevention (CDC; Atlanta), the National Health Interview Survey.

Finklestein's objective was to measure the prevalence of COPD across age groups and to establish whether the condition is an identifiable risk factor in cardiovascular disease (CVD). The diagnosis of CVD was assigned based on the diagnosis of the respondent's physician, and data from respondents younger than the age of 40 were not included in this analysis. Data from participants who had not smoked at least 100 cigarettes over the course of their life were also excluded.

According to the CDC data, more men than women had emphysema, and more women had chronic bronchitis. Oddly enough, the data showed that of COPD patients, "almost half of them continued smoking" after diagnosis, he said. They were also more likely to be regular drinkers and less likely to exercise.

The raw numbers suggested that about one in four of the respondents who did not have COPD had CVD, but 56.5% with COPD did have CVD. Another interesting finding was that "being Hispanic and having a higher level of education were associated with lower risk" of CVD, even in the presence of COPD, Finklestein said. He told CDU that the fact that there is no cure for COPD might explain the persistence of tobacco use in this population.

Veronica Sansing, a researcher at the Center for Minority Health at the University of Pittsburgh, discussed a study that examined how blacks and whites report their impressions of their general health and how closely those reports tracked clinical indices of health. For this study, Sansing and her co-authors looked at patients with Type 2 diabetes who had undergone coronary bypass and angioplasty to treat congestive heart disease.

Sansing said that it was not surprising that African Americans reported poorer health, but "what was surprising was how much more poorly African Americans reported their health." She said that the phenomenon "carries over to other diseases," but "there's a lack of research into pessimism and diseases."

Sansing reminded the audience that "risk factors for Type 2 diabetes and coronary artery disease (CAD) are more prevalent in blacks compared to non-Hispanic whites.

The study enrolled a total of 1,199 subjects. Of these, 333 were black and the balance of 866 was made up of whites of non-Hispanic ancestry. "Only black and white subjects were analyzed," she said, citing unspecified problems with widening the study population.

"White patients were mainly male and had an average age of 64," but "less than half of blacks were male," Sansing said. Blacks were less likely to be married or to have finished high school, and whites were more likely to have a hypoglycemic episode while blacks were more likely to have chronic renal dysfunction. She also said of white patients that some factor correlated with self-reports of fair or poor health, such as education, but that this particular effect was not seen in blacks. However, diabetic neuropathy correlated to fair or poor self-reports for both groups.

Some potential confounders not examined in the study were dental health and psychosocial factors, both of which Sansing said were "shown to be highly correlated" with those with Type 2 diabetes. However, the analysis worked out most of the observed factors and the conclusion was that "health pessimism was more common in black patients than white patients," and that under these circumstances, self-reported health was less predictive of clinical health.

Sansing told CDU that the medical literature does include data on depression as distributed across racial groups, and that depression "has been found to impact" self-reported health status.