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Percutaneous coronary intervention (PCI) has survival and MI-prevention benefits in patients with acute coronary syndromes (ACS), but do these benefits extend to stable CAD patients?
In the COURAGE trial, 2287 patients (mean age, 62; 85% men; 33.5% with diabetes; mean left-ventricular ejection fraction [LVEF] 61%) were randomized to PCI plus optimal medical therapy or to optimal medical therapy alone. All patients had either ≥70% stenosis with objective evidence of ischemia or ≥80% stenosis with classic angina. Patients with a markedly positive stress test or an LVEF <30% were excluded.
Of the PCI group, 94% received stents (97% bare-metal). Both groups had high rates of receiving optimal medical therapy and of adhering to healthful lifestyle interventions; they each achieved mean LDL-cholesterol levels of just above 70 mg/dL. Median follow-up was 4.6 years.
The incidence of death or MI (the primary outcome) was similar in both groups (about 19%), as were the incidences of hospitalization for ACS and stroke. The PCI group had a significantly lower revascularization rate during follow-up (21% vs. 33% with medical therapy alone), and they had a significant advantage in freedom from angina at 1 year (66% vs. 58%) and 3 years (72% vs. 67%) but not at 5 years (74% vs. 72%).
Boden WE et al. for the COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007 Mar 27; [Epub ahead of print]. (http://content.nejm.org/cgi/content/short/NEJMoa070829)
Hochman JS and Steg PG. Does preventive PCI work? N Engl J Med 2007 Mar 27; [Epub ahead of print]. (http://content.nejm.org/cgi/content/short/NEJMe078036)
Comment
In patients with stable CAD, the roughly 5-year incidence of death or MI was similar with PCI and optimal medical therapy alone, although PCI showed some advantage in relieving angina. As the editorialist notes, fewer than 10% of screened patients were eligible for this trial, and fewer than 75% of eligible patients were enrolled, raising questions about the generalizability of the results. On balance, the data highlight the benefits of optimal medical therapy in patients with stable CAD who do not have stress-test results that suggest high risk for events. The findings confirm the current guideline recommendation that PCI can be safely deferred in these patients.