Medical therapy, PCI equivalent on clinical outcomes in patients with stable CAD

Percutaneous intervention (PCI) plus optimal medical therapy as an initial strategy is no better than optimal medical therapy alone in preventing death or major cardiovascular events in patients with coronary artery disease (CAD) and myocardial ischemia, said William E. Boden, MD (pictured left), at the American College of Cardiology's 56th annual scientific session.

This unexpected finding comes from a study known as COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), in which 2,287 patients with stable CAD were randomized to one of the two treatment strategies.

To be included in COURAGE, patients had to have stable CAD, a stenosis of at least 70% in at least one proximal coronary artery, and objective evidence of myocardial ischemia on an electrocardiogram (or a stenosis of at least 80% and angina without provocative testing).

"The criteria were chosen to ensure a high-risk population," said Dr. Boden, professor of medicine and public health at the University of Buffalo, New York. "We wanted to give angioplasty the best possible opportunity to show benefit."

All patients received aggressive therapy to lower low-density lipoprotein cholesterol levels to a target of

After a median follow-up of 4.6 years, 18.5% of those assigned to medical therapy alone and 19.0% assigned to PCI plus medical therapy had an event. Incidence of the combined endpoint of death, myocardial infarction (MI), or stroke was 19.5% in the patients randomized to optimal medical therapy alone and 20.0% in those randomized to PCI/optimal medical therapy. There was a nonsignificant trend toward fewer MIs in the patients treated with medicine only vs. PCI/medicines (12.3% vs. 13.2%, p = 0.33).

PCI did have an initial advantage in relieving angina but this advantage declined over time until it virtually disappeared by the study's conclusion. "Within 1 year, close to 60% of the medically treated patients were angina-free," said Dr. Boden, "with no between-group difference in angina-free status at 5 years."

The COURAGE findings reinforce existing guidelines from the American Heart Association and the American College of Cardiology that state that PCI can be safely deferred in patients with stable CAD, even in those with extensive multivessel involvement and inducible ischemia.

"There was an implicit belief that PCI would reduce the chance of having an MI and dying," Dr. Boden said. "We found that patients were at no more and no less of a risk of having an event or dying if you defer stenting."

He said that treating patients to targets for blood pressure, lipids, and blood glucose is important for stabilizing a systemic disease that takes decades to manifest. "We may be stabilizing plaques that are about to rupture," he added.