BMJ  2007;334:813-814 (21 April), doi:10.1136/bmj.39185.447315.3A

Letters

Coronary artery disease

Case presented does not wash

COURAGE comes hard on the heels of a recent cost effectiveness analysis that showed that the huge costs of angioplasty compared with medical treatment could not be justified.^{1 2} The study confirms that angioplasty does not improve prognosis in patients with stable angina, and this should clarify a common misunderstanding in the minds of commissioners and patients.³

Thomas (previous letter) says that it is important to note that 43% of patients in the COURAGE study had little or no angina. It is worrying that such patients should have been exposed to the risk of harm that is inherent in palliative angioplasty, but Thomas should recall that the proportion of patients randomised to palliative angioplasty in the landmark RITA trial was 45%.⁴

The finding that one third of the COURAGE patients randomised to medical treatment later underwent angioplasty should be balanced by the fact that 20% of the angioplasty group also underwent further angioplasty during follow up. Given the common practice of recommending angioplasty to patients who do not have significant angina, it is highly likely that a high proportion of these patients had little or no angina.

Thomas argues that most angioplasty procedures in the United Kingdom are used to treat patients with unstable syndromes. Yet the national audit data presented to the 2006 annual meeting (available to download from www.bcis.org.uk) showed that 56% of the 70 142 angioplasty procedures in 2005 were for stable angina. COURAGE and the data provided by Griffin et al² combine to suggest that most of these were a costly waste. In the current value for money climate, primary care trusts will be obliged to look much more carefully at the resources they commit to the 40 000 or so palliative angioplasty procedures currently undertaken.⁵

National Refractory Angina Centre, Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool L14 3PE

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Competing interests: The National Refractory Angina Centre provides advice and training to commissioners who want to rationalise palliative revascularisation costs.

References

1. Mayor S. Drugs are as good as PCI in stable coronary artery disease, study shows. BMJ 2007;334: 713. (7 April.) doi: 10.1136/bmj.39174.633403.DB[Free Full Text]
2. Griffin SC, Barber JA, Manca A, Sculpher MJ, Thompson SG, Buxton MJ, et al. Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study. BMJ 2007;334:624. (24 March.)[Abstract/Free Full Text]
3. Bridson J, Hammond C, Leach A, Chester MR. Making consent patient centred. BMJ 2003;327:1159-61.[Free Full Text]
4. RITA-2 Trial Participants. Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. Lancet 1997;350:461–8.[CrossRef][ISI][Medline]
5. Chester MR, Kingsland J. Timely fillip for practice based commissioning. bmj.com 2007. www.bmj.com/cgi/eletters/334/7594/624#162274.

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