Study Analyzes Optimal Medical Therapy With PCI Since the Publication of COURAGE

May 11, 2011—In the Journal of the American Medical Association, William B. Borden, MD, et al published an analysis of patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention (PCI) before and after the publication of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) study (2011;305:1882–1889).

The investigators noted that COURAGE provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of PCI on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), which suggests that a trial period of OMT is warranted before PCI. However, it is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial. The objective of the current study was to examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial.

As detailed in the Journal of the American Medical Association, the investigators conducted an observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. OMT was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agents, beta blockers, and statins). The main outcome measures were the rates of OMT before PCI and at discharge (following PCI) between the two study periods.

The investigator reported that among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%–44.4%) before PCI and in 303,864 patients (65 %; 95% CI, 64.9%–65.2%) at discharge following PCI (P < .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%–43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%–44.8%) after the COURAGE trial (P < .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%–63.7%) and 66% (95% CI, 65.8%–66.1%), respectively (P < .001).

The investigators concluded that among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after the publication of the COURAGE trial.

The Society for Cardiovascular Angiography and Interventions (SCAI) commented that the study highlights the need for increased collaboration between referring physicians and interventional cardiologists to ensure patients who may benefit from OMT are managed appropriately before PCI is considered or deemed necessary. SCAI noted that it is implementing several quality improvement initiatives to improve patient outcomes and reduce costs, including the first accreditation of a PCI program/catheterization lab by the Accreditation for Cardiovascular Excellence program and the launch of a quality toolkit to be implemented in hospital catheterization labs nationwide. These initiatives were announced on May 5 at the SCAI annual meeting and summarized in the Cardiac Interventions Today news.

In the March/April 2011 issue of Cardiac Interventions Today, Matthew J. Sorrentino, MD, discusses OMT for patients with chronic coronary disease after PCI (2011;5:33–38).