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http://www.theheart.org/
Mar 8, 2004 Exercise offers higher event-free survival than PCI, at half the cost
Leipzig, Germany - In patients with stable coronary artery disease, a daily 20-minute exercise program can achieve higher event-free survival and better exercise capacity at low cost compared with PCI, researchers at the University of Leipzig found.[ 1] The results of the 101-patient trial were published March 8, 2004 as a rapid-access publication in Circulation.
One year after the intervention, 88% of patients in the exercise group had survived free of events, compared with 70% in the PCI group, with similar improvement of clinical symptoms in both groups. "The study was too small to make a general recommendation, but it suggests that patients with coronary artery disease can get the same symptom relief by exercising as they could with PCI and stenting," said lead investigator Dr Rainer Hambrecht (University of Leipzig, Germany). "In addition, those willing to spend their leisure time exercising may have fewer clinical events." With technical advances in recent years, PCI has become the therapy of choice in CAD patients. Still, however, complications may occur during the procedure, and reinterventions due to restenosis are frequent. Exercise therapy, on the other hand, can improve myocardial perfusion and exercise tolerance and slow the progression of CAD. Based on these favorable effects, Hambrecht and colleagues compared 12 months of exercise training with medical therapy as the first-line treatment with standard PCI in 101 male patients with stable CAD, aged 70 or younger, in terms of clinical symptoms, exercise capacity, myocardial perfusion, cost-effectiveness, and a combined end point of cardiac death, stroke, CABG, angioplasty, acute MI, and worsening angina. At baseline, patients had class I-III angina, according to the Canadian Cardiovascular Society (CCS) class. The exercise group engaged in 10 minutes of training on a bicycle ergometer six times a day for the first two weeks in the hospital and 20 minutes of training at home thereafter and were also encouraged to participate in a weekly group training session. Exercise outscores PCI, at a bargainDuring follow-up, 21 events occurred in the PCI group, which amounted to an event-free survival of 70%. People who participated in regular training for 12 months faired significantly better, with only six events and an event-free survival of 88%. At one year, symptoms had improved significantly in both groups, with average CCS class decreasing from 1.5 to 0.4 in patients engaged in exercise training and from 1.7 to 0.7 in patients who underwent PCI. While maximal exercise tolerance increased by 20%, ischemic threshold by 30%, and maximal oxygen uptake by 16% in the training group, PCI was associated only with a marked elevation of the ischemic threshold but showed no improvements on the other two variables. One-year assessments vs baseline in exercise and PCI patients
Mean CAD progression according to the grading system was greater in the PCI group (0.81) than in the training group (0.30). CAD progressed in a total of 32% of exercise patients compared with 45% of PCI patients. Moreover, better outcomes in the exercise group were achieved at about half the cost of the interventional procedure. The $6956 price tag of stenting for each one-class improvement was undercut substantially by the exercise program, which ran at $3429 for each one-class improvement. The higher costs of PCI resulted from the steep initial cost of the procedure and more frequent reinterventions, the authors write.
Due to these apparent advantages of exercise therapy, which had already been observed in earlier studies, Hambrecht advocates a more frequent use of training as a first-line therapy in patients with stable CAD. "Indeed, in patients who are motivated to change their lifestyle and to engage in physical activity it would make sense to initially start with the training program, and often these patients do not need PCI any longer," he said in an interview with heartwire . "Unfortunately, it has become routine practice to dilate patients immediately after diagnosis, which eliminates the exercise option." Motivation is key to successIn addition, physical activity can initiate improvements that are associated with general lifestyle changes. Often CAD patients lead a sedentary lifestyle, which is not affected by an interventional procedure, as observed in this study. In contrast to the exercise group, PCI patients did not show improvements in exercise tolerance or maximal oxygen. Thus, "an optimized medical therapy together with exercise training can be an alternative approach to an interventional strategy in selected motivated patients with stable CAD," Hambrecht pointed out. He explained that motivation, indeed, is key to the success of a long-term exercise program and thinks that physicians should promote exercise training much more aggressively and less often revert to procedures offering fast relief. "It takes time and effort to organize the programs and you can't make money with it. PCI is a lot easier, but more expensive," he said. "Given the higher event rates with PCI, the value of PCI in terms of more rapid relief of symptoms must be critically weighed against the inherent risks and greater total costs of the procedure," Hambrecht's group concluded.
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