TY - JOUR
T1 - Placing COURAGE in context
T2 - Review of the recent literature on managing stable coronary artery disease
AU - Coylewright, Megan
AU - Blumenthal, Roger S.
AU - Post, Wendy
PY - 2008/7
Y1 - 2008/7
N2 - Coronary artery disease (CAD) is the leading cause of death in the United States, but prevention and intervention efforts are lowering mortality. This progress is being undercut by rising rates of obesity and diabetes, and adherence to evidence-based prevention efforts is less than ideal. Many patients with CAD who are asymptomatic or have minimal symptoms undergo percutaneous coronary intervention (PCI) each year, even though PCI has not been demonstrated to improve survival for this group. Motivated by the recent controversy surrounding the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, we reviewed randomized clinical trials with follow-up published in the past decade comparing medical management with revascularization for stable CAD to provide a context for the COURAGE trial. We searched for relevant studies published from January 1, 1997, until the date of electronic publication of the COURAGE study results, March 26, 2007; references cited in the COURAGE publication were also reviewed. Evidence shows that PCI does not decrease mortality or risk of myocardial infarction over optimal medical or lifestyle therapy in patients with chronic stable CAD. In published studies, early benefits in angina control afforded by revascularization wane over time; this could change with modern interventional therapies. The final word is not that medical therapy is superior for all patients, but that optimizing medical and lifestyle therapy is appropriate as an initial management strategy for most patients who do not have unstable or disabling symptoms. It is essential that systems are set in place to make the medical management of patients with CAD second nature; this focus could be one of the most powerful results of the COURAGE trial.
AB - Coronary artery disease (CAD) is the leading cause of death in the United States, but prevention and intervention efforts are lowering mortality. This progress is being undercut by rising rates of obesity and diabetes, and adherence to evidence-based prevention efforts is less than ideal. Many patients with CAD who are asymptomatic or have minimal symptoms undergo percutaneous coronary intervention (PCI) each year, even though PCI has not been demonstrated to improve survival for this group. Motivated by the recent controversy surrounding the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, we reviewed randomized clinical trials with follow-up published in the past decade comparing medical management with revascularization for stable CAD to provide a context for the COURAGE trial. We searched for relevant studies published from January 1, 1997, until the date of electronic publication of the COURAGE study results, March 26, 2007; references cited in the COURAGE publication were also reviewed. Evidence shows that PCI does not decrease mortality or risk of myocardial infarction over optimal medical or lifestyle therapy in patients with chronic stable CAD. In published studies, early benefits in angina control afforded by revascularization wane over time; this could change with modern interventional therapies. The final word is not that medical therapy is superior for all patients, but that optimizing medical and lifestyle therapy is appropriate as an initial management strategy for most patients who do not have unstable or disabling symptoms. It is essential that systems are set in place to make the medical management of patients with CAD second nature; this focus could be one of the most powerful results of the COURAGE trial.
UR - http://www.scopus.com/inward/record.url?scp=46749159233&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=46749159233&partnerID=8YFLogxK
U2 - 10.4065/83.7.799
DO - 10.4065/83.7.799
M3 - Review article
C2 - 18613996
AN - SCOPUS:46749159233
SN - 0025-6196
VL - 83
SP - 799
EP - 805
JO - Mayo Clinic proceedings
JF - Mayo Clinic proceedings
IS - 7
ER -