David J. Maron, MD


December 19, 2008


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Percutaneous coronary intervention, or "PCI," has become routine treatment for stable angina. The COURAGE trial tested the superiority of adding PCI to medical therapy for initial management of stable coronary disease compared with medical therapy alone. Over 2200 patients with evidence of ischemia and 1 or more coronary stenoses > 70% were randomized to PCI with optimal medical therapy, or "OMT," vs OMT alone. Patients were followed for an average of 4.5 years. OMT patients were allowed to cross over to revascularization if they had progressive or refractory symptoms.

Three main analyses from COURAGE have been published. The first found no difference in the rate of death or MI between the 2 treatment strategies.[1] The second found that PCI was better at controlling angina than OMT, but the benefit was modest and disappeared after 2 years. Most of the benefit from PCI was in patients with severe angina, and OMT alone was surprisingly effective at treating most patients.[2,3] The third analysis found that PCI cost approximately $10,000 more per patient without any significant gain in life-years or quality-adjusted life-years. The per patient cost of significant angina improvement from PCI was $150,000.[4]

Based on COURAGE, it is difficult to defend a routine strategy of up-front PCI in patients with stable angina. Optimal medical therapy should be routine first-line therapy, with PCI reserved for patients with severe baseline angina or symptoms unresponsive to medical therapy. This makes it incumbent upon those of us who treat patients with stable angina to provide comprehensive and intensive medical therapy, and tailor subsequent therapy based on the patients' response. This is challenging in a healthcare system that provides strong financial reward for PCI and little incentive to provide optimal medical therapy, but this is what evidence-based medicine is supposed to be.

That's my opinion. I'm Dr. David Maron, Associate Professor of Medicine and Emergency Medicine at Vanderbilt University, Nashville, Tennessee.



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