Based Upon the Results of the COURAGE Clinical Trial, What Is the Best Treatment for Stable Angina?

Raymond J. Gibbons, MD; George D. Lundberg, MD

Disclosures

December 05, 2007

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Good morning. I'm Dr. George Lundberg, Editor-in-Chief of Medscape General Medicine. We're on the floor of the convention center at the American Heart Association meeting in Orlando, Florida, this year, and we're pleased to be able to bring you a conversation with Dr. Raymond J. Gibbons. Let me read this resume briefly: bachelor's Princeton; aerospace, MS in mathematics from Oxford; another MS from Hopkins; a Harvard and MIT together MD; Mass General for internal medicine; Duke cardiology; and then he has been at Mayo ever since that time. I never read a more impressive early time. Why haven't you done anything ever since then?

Raymond J. Gibbons, MD: I eat and sleep like everybody else.

George D. Lundberg, MD: Yes, I'm sure you do, but congratulations on your academic achievements.

Dr. Gibbons: Well, thank you.

Dr. Lundberg: It was a forerunner of a lot of good things. Let's talk about cardiology, and let's talk about angina pectoris: stable, unstable. Stable is more common?

Dr. Gibbons: Stable is much more common, and I think it's of more current interest. Our management of stable angina has obviously consisted of medications. But we knew from randomized trials in bypass surgery conducted 20 years ago that certain patients with very severe problems, particularly left main disease and 3-vessel disease with prior abnormal ventricular function, benefited from surgery from the standpoint of survival. As percutaneous coronary intervention [PCI] came along, we thought that patients who had less severe coronary artery disease probably would benefit, from the standpoint of survival and myocardial infarction, from PCI.

Dr. Lundberg: That's sensible.

Dr. Gibbons: And that was incorporated into national guidelines. This year, however, there have been 2 studies that have been published, OAT and COURAGE, that have both challenged that assumption. I think the study that is most pertinent to chronic stable angina is COURAGE. In a large trial conducted in the VA [Veterans Administration], certain other academic medical centers in the United States, including my own, and Canada, the investigators showed that with optimal medical therapy.

Dr. Lundberg: Okay. What do you call that? What is optimal medical therapy?

Dr. Gibbons: Well, previous trials had focused on just relieving angina. That trial had a different comprehensive approach: risk factor reduction. They just didn't treat angina, they also treated the risk factors very aggressively, and did very well even after 5 years at meeting targets for LDL [low density lipoprotein], for blood pressure, getting patients to stop smoking, getting them to exercise. And compared to optimal therapy, optimal therapy plus PCI did not convey an advantage with respect to heart attack or death. That was news, challenging the assumption that we had all along. It has led to a decrease, already, in the use of stents in the country. And I think it poses a challenge for practicing physicians to do as well with medical therapy in treating risk factors and symptoms, as occurred in the trial.

Dr. Lundberg: And of course, one of the things they have to do is handle patient compliance in terms of long-term use of whatever they're supposed to do.

Dr. Gibbons: I think they need to be very clear on educating the patient about the importance of, not just treatment for their chest pain, but treatment for the plaque and underlying coronary artery disease to prevent events. The patients have to understand the importance of taking aspirin, the importance of lowering their cholesterol to appropriate targets -- ideally an LDL of less than 100 -- and also not to smoke.

Dr. Lundberg: Of course, we live in a society with a medical-industrial complex with huge amounts of money that flow through the system into lots of people's pockets. If you're going to do surgery, or if you're going to do percutaneous stent implants, etc, it probably accrues a lot more money to people who are doing it, and it costs the insurance companies and the government a lot more to do that. So, there must be a tension developing there.

Dr. Gibbons: There's a clear tension, and I think there is an undercurrent of concern raised about the trial. For example, there's a tendency to point out there was a modest difference in pain relief, but it was modest. It was less than 10% of the patients had more complete pain relief by PCI at a year, and that [number] diminished over subsequent management of the patients. And a very comprehensive quality-of-life cost-effectiveness analysis presented here at the American Heart Association meeting this year by Dr. Weintraub, an expert in cost-effectiveness, showed that no matter what assumption you made, the effect on quality of life was minimal and very cost-ineffective.

Dr. Lundberg: So, for a stable angina at this time, optimal medical therapy is the best way to go?

Dr. Gibbons: It's clearly the best way to go. The challenge for all of us in the healthcare system is to do the best job we can of getting patients to comply with guideline-indicated medications.

Dr. Lundberg: There you are. Thank you all for being with us today. We've been talking with Dr. Raymond Gibbons, professor of medicine at the Mayo Clinic College of Medicine and a former president of the American Heart Association. Thank you for being with us. And thank you for being with us.

 


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