Still No Mortality Benefit for PCI in Stable Ischemia

By Harlan Krumholz, MD, SM

Dr. Krumholz is editor-in-chief of NEJM Journal Watch Cardiology, from which this story was adapted. See full coverage at the link below.

Percutaneous coronary intervention (PCI) for the treatment of stable ischemic heart disease offers no longer-term survival benefit compared with initial medical therapy alone, according to a new analysis from the COURAGE trial published in the New England Journal of Medicine.

Extended follow-up data were available for about half of the original 2287 patients. In the original follow-up (median, 4.6 years), all-cause mortality did not differ significantly between PCI and medical therapy (25% and 24%, respectively). Now, in the extended follow-up (median, 11.9 years), there also was no significant mortality difference (41% and 42%, respectively).

Of note, during the original follow-up period, one third of medical-therapy patients crossed over to coronary revascularization, at a median interval of 11 months. However, there were no data on crossover during the extended follow-up.

This follow-up of the COURAGE cohort fails to find a longer-term survival benefit but suffers from many limitations. The study assesses the question of early strategy, which in many cases asked whether an invasive strategy could be deferred because so many people receiving medical therapy eventually cross over. The debates about this study are likely to persist, but those who believe in PCI still lack strong evidence that it reduces hard events.