Optimal medical therapy utilization prior to PCI significantly decreased after the publication of the COURAGE trial (32.8% vs 34.9% before publication, P<0.001).
Cohort (n=23,680)
What are the practice patterns and trends in the use of optimal medical therapy before and after PCI in older patients with stable CAD, and did the COURAGE study alter these patterns?
Despite clinical guidelines and the COURAGE trial emphasizing medical therapy for stable CAD, optimal medical therapy remains significantly underutilized both before and after PCI, with rates paradoxically decreasing after the COURAGE publication.
Absolute Event Rate: 32.8% vs 34.9%
p-value: p=<0.001
BACKGROUND: Clinical guidelines emphasize medical therapy as the initial approach to the management of patients with stable coronary artery disease (CAD). However, the extent to which medical therapy is applied before and after percutaneous coronary intervention (PCI) in contemporary clinical practice is uncertain. We evaluated medication use for patients with stable CAD undergoing PCI, and assessed whether the COURAGE study altered medication use in the Canadian healthcare system. METHODS AND RESULTS: A population-based cohort of 23 680 older patients >65 years old) with stable CAD undergoing PCI in Ontario between 2003 and 2010 was assembled. Optimal medical therapy (OMT) was defined as prescription for a β-blocker, statin, and either angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker in the 90 days before PCI, and the same medications plus thienopyridine 90 days following PCI. Prior to PCI, 8023 (33.9%) patients were receiving OMT, 11 891 (50.2%) were on suboptimal therapy, and 3766 (15.9%) were not prescribed any medications of interest. There was significant improvement in medical therapy following PCI (OMT: 11 149 47.1%, suboptimal therapy: 11 591 48.9%, and none: 940 4.0%, P<0.001). Utilization rate of OMT reduced significantly after the publication of COURAGE (34.9% before versus 32.8% after, P<0.001). Similarly, the rate of OMT following PCI was lower in the period after publication of COURAGE (47.3% before versus 46.9% after, P<0.001). CONCLUSIONS: OMT was prescribed in about 1 in 3 patients prior to PCI and less than half after PCI. In contrast to the anticipated impact of COURAGE, we found lower rates of medication use in PCI patients after its publication.
Garg et al. (Thu,) conducted a cohort in Stable coronary artery disease undergoing PCI (n=23,680). Optimal medical therapy (OMT) vs. Before vs after COURAGE trial publication was evaluated on Utilization rate of OMT prior to PCI before versus after the publication of COURAGE (p=<0.001). Optimal medical therapy utilization prior to PCI significantly decreased after the publication of the COURAGE trial (32.8% vs 34.9% before publication, P<0.001).