Does PCI added to drug therapy improve outcomes in stable CAD?

Journal of Family Practice, July, 2007 by W.E. Boden, O'Rourke R.A., K.K. Teo

* Clinical question

Do percutaneous coronary interventions (PCIs) improve outcomes when added to optimal medical therapy for patients with stable coronary disease?

* Bottom line

No. Optimal medical therapy--treatment with a statin, an antiplatelet agent, an anti-anginal medication, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker--was as effective as pairing it with percutaneous coronary interventions (PCIs) for patients with stable coronary artery disease (CAD).

Level of evidence

1b: Individual randomized controlled trial (with narrow confidence interval)

Study design

Randomized controlled trial (single-blinded)

Funding

Industry and government

Allocation

Concealed

Setting

Outpatient (specialty)

Synopsis

Despite the fact that guidelines recommend optimal medical therapy as the first-line treatment for stable CAD, 85% of patients undergoing PCI each year have stable CAD as the indication.

In this study, 2287 patients with stable angina were randomly assigned to receive intensive medical therapy or PCI followed by the same course of intensive medical therapy. All had at least 1 proximal vessel with 70% stenosis and evidence of myocardial ischemia (95% of patients) or at least 1 proximal vessel with 80% stenosis accompanied by classic angina without provocative testing. Patients with persistent class W angina, heart failure, recent revascularization, anatomy not suitable for PCI, or a markedly positive stress test result were excluded.

Intensive medical therapy consisted of aspirin or clopidogrel, metoprolol, amlodipine and/or isosorbide mononitrate, and lisinopril or losartan. Simvastatin (Zocor) with or without ezetimibe (Zetia) was used to achieve a target low-density lipoprotein cholesterol level of <85 mg/dL (2.2 mmol/L). Exercise, extended-release niacin, and fibrates were used to achieve a high-density lipoprotein cholesterol level of >40 mg/dL (1.03 mmol/L) and a triglyceride level of <150 mg/dL (1.67 mmol/L). Most patients did not receive a drug-eluting stent.

The mean age of patients was 61 years, 85% were men, and 86% were white. Groups were balanced at the start of the study. Analysis was by intention to treat, and patients were followed up for a mean of 4.6 years. Outcomes were assessed by researchers masked to treatment assignment.

All but 46 of 1149 patients in the PCI group received the intervention; of those receiving a stent, 41% received more than one. Medical therapy was similarly intensive in both groups.

The primary outcome was a composite of death or nonfatal myocardial infarction. There was no difference between groups (19% in each) and also no significant difference in the likelihood of all-cause mortality (8% in each group).

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FAST TRACK

Percutaneous interventions did not result in lower rates of death or nonfatal MI

Boden WE, O'Rourke RA, Teo KK, et al, for the COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356:1503-1516.