Did the publication of the COURAGE trial increase the use of optimal medical therapy before and after PCI in patients with stable CAD?
Less than half of patients with stable CAD receive optimal medical therapy before PCI, and only two-thirds receive it at discharge, with minimal improvement following the publication of the COURAGE trial.
CONTEXT: The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial. OBJECTIVE: To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial. DESIGN, SETTING, AND PARTICIPANTS: 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. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin). MAIN OUTCOME MEASURES: Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods. RESULTS: 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 (65.0%; 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 66.0% (95% CI, 65.8%-66.1%), respectively (P < .001). CONCLUSION: 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 publication of the COURAGE trial.
William B. Borden (2011) studied this question.