COURAGE and Management of Stable CAD
Abstract & Commentary
By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman reports no financial relationship to this field of study.
Synopsis: Optimizing medical and lifestyle change therapy rather than performing PCI is appropriate as the initial management strategy for most patients with known CAD who do not have unstable or disabling symptoms.
Source: Coylewright M, et al. Placing COURAGE in context: Review of the recent literature on managing stable coronary artery disease. Mayo Clin Proc 2008;83:799-805.
Despite a recent decrease in overall mortality, coronary artery disease (CAD) remains the leading cause of death for both men and women in the United States, especially because of the rising rates of obesity and diabetes.1 It has been clearly demonstrated that early percutaneous coronary intervention (PCI), in patients suffering acute myocardial infarctions (MI) with ST-segment elevation2 and/or in MI patients with unstable angina without ST-segment elevation, is of benefit.3 This procedure improves survival and reduces the incidence of death or nonfatal MI compared with medical therapy alone, assuming the procedure is performed within the narrow time window that has been demonstrated to produce the best results.4 Current guidelines recommend PCI in patients with stable CAD only after failed medical therapy and/or upon demonstrating high-risk coronary anatomy5; however, many patients who are asymptomatic or who have only minimal symptoms are still subjected to PCI.6 In fact, the number of nonsurgical coronary interventions has continued to rise, with 758,000 procedures performed in 2005.7 It should also be noted that at least a third of these procedures were considered to be elective in nature.8,9
Boden and colleagues published the important Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation Trial (COURAGE), which compared PCI vs aggressive medical therapy in 2007.10 The conclusions raised by this article stimulated widespread debate in cardiology circles and, as a result, Coylewright and colleagues from Johns Hopkins University Department of Epidemiology reviewed relevant outcome studies published after Jan. 1, 1997, until the day of publication of the COURAGE study results on March 26, 2007.11 In addition, they reviewed numerous published studies that were referenced in the COURAGE report. Their review focused on specific trials10,12-15 and they observed that PCI did not decrease mortality or risk of MI to a greater degree than did optimal medical therapy and/or lifestyle change in patients with chronic stable CAD. Early symptomatic improvement in angina symptoms produced by PCI revascularization was found to wane over time and they concluded that optimum medical therapy and lifestyle change were preferable to PCI as the initial management strategies for most patients who do not have unstable or disabling symptoms secondary to CAD.
Commentary
Critics of the COURAGE trial have suggested that the results incorrectly favored medical therapy primarily because of study flaws,16 whereas supporters have provided counter-arguments that affirmed the study's conclusions.13,17,18 Despite the initial vigorous debate among cardiologists, it would appear that Coylewright's review11 of the recent published literature confirms that PCI does not decrease mortality or risk of MI compared to optimal medical therapy and/or lifestyle change in patients with chronic stable CAD. It is increasingly apparent that a conservative approach to patients with stable CAD is the best first-line treatment in most clinically stable CAD patients. Treatment of hyperlipidemia, hypertension, obesity, diabetes mellitus, and encouraging patients to eat an appropriate diet, exercise regularly, etc., will all help prevent or diminish endothelial dysfunction, which may lead to plaque disruption and thrombosis, inflammation, and abnormal vasomotor tone. Finally, it is important to note that many patients managed medically who improved have a low rate of adherence both to guidelines and medication recommendations21; therefore, it is important that medical management of the increasing number of patients with CHD become second nature for physicians21,22 to achieve the needed results. It is essential that patient compliance be improved by any and all techniques available to the medical profession; improved compliance will undoubtedly permit physicians to spend more time educating patients and encouraging them to remain compliant on a permanent basis to avoid clinical deterioration.
In summary, because most plaques responsible for ACS are not obstructive and intensive medical therapy (cholesterol-lowering statin and antiplatelet therapy, ACE inhibitors, beta-blockers, etc.) and lifestyle change can effectively treat ACSs without the need for PCI,20 intensive medical therapy instead of PCI should be the first therapeutic approach for most, if not all, patients with stable CAD.
References
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2. Antman EM, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee to revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol 2004:44:e1-e211.
3. Braunwald E, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarctionsummary article: A report of the American College of Cardiology/ American Heart Association task force on practice guidelines (Committee on the Management of Patients with Unstable Angina). J Am Coll Cardiol 2002;40:1366-1374.
4. Hochman JS, et al; Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006;355:2395-2407.
5. Gibbons RJ, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable anginasummary article: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation 2003;107:149-158.
6. Lin GA, et al. Cardiologists' use of percutaneous coronary interventions for stable coronary artery disease. Arch Intern Med 2007;167:1604-1609.
7. Levit K, et al. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2005. Agency for Healthcare Research and Quality. Available at: www.hcup-us.ahrq.gov/reports.jsp. Accessed Sept. 5, 2008.
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10. Boden WE, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.
11. Coylewright M, et al. Placing COURAGE in context: Review of the recent literature on managing stable coronary artery disease. Mayo Clin Proc 2008;83:799-805.
12. Pitt B, et al. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorovastatin versus Revascularization Treatment Investigators. N Engl J Med 1999;41:70-76.
13. Coronary angioplasty versus medical therapy for angina: The second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants. Lancet 1997;350:461-468.
14. Hueb W, et al. The medicine, angioplasty, or surgery study (MASS-II): A randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: One year results. J Am Coll Cardiol 2004;43:1743-1751.
15. Erne P, et al. Effects of percutaneous coronary intervention in silent ischemia after myocardial infarction: The SWISSI II randomized controlled trial. JAMA 2007; 297:1985-1991.
16. Yusuf S, et al. Clinical decisions. Management of stable coronary disease. N Engl J Med 2007;357:1762-1766.
17. Diamond GA, Kaul S. COURAGE under fire: On the management of stable coronary disease. J Am Coll Cardiol 2007;50:1604-1609.
18. Kereiakes DJ, et al. The truth and consequences of the COURAGE trial. J Am Coll Cardiol 2007;50:1598-1603.
19. Blumenthal RS, et al. Task force 10: Training in preventive cardiovascular medicine. J Am Coll Cardiol 2008; 51:393-398.
20. Levine GN, et al. Cholesterol reduction in cardiovascular disease. Clinical benefits and possible mechanisms. N Engl J Med 1995;332:512-521.
21. Smith SC Jr. Evidence-based medicine: Making the grade: Miles to go before we sleep (editorial). Circulation 2006;113:178-179.
22. Gluckman TJ, et al. A simplified approach to the management of non-ST-segment elevation acute coronary syndromes. JAMA 2005;293:349-357.
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