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Influence of COURAGE trial on optimal medical therapy use small

Borden WB. JAMA. 2011;305:1882-1889.

Issue: June 2011

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During the years after the publication of the COURAGE trial results, few changes were observed in the practice patterns of optimal medical therapy use among patients with stable coronary artery disease undergoing percutaneous coronary intervention, according to a new study.

In 2007, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) data indicated that PCI and optimal medical therapy (OMT) did not improve survival or prevent MI in patients with stable CAD compared with OMT alone.

In the current analysis, researchers set out to find the influence of these results on clinical practice. The observational study featured 467,211 patients (37.1% before, 62.9% after COURAGE publication) with stable CAD undergoing PCI from the National Cardiovascular Data Registry between Sept. 1, 2005, and June 30, 2009. Researchers defined OMT as either being prescribed or having a documented contraindication to medicines, including antiplatelet agents, beta-blockers and statins.

Overall, 206,569 patients were treated with OMT before PCI and 303,864 were treated at discharge after PCI. Before the COURAGE trial, OMT before PCI was used in 43.5% of patients (n=75,381), whereas after the trial, it was used in 44.7% of patients (n=131,188). Additionally, OMT use at discharge after PCI was 63.5% before the COURAGE trial and 66% after the trial.

“Collectively, these findings suggest a significant opportunity for improvement and a limited effect of an expensive, highly publicized clinical trial on routine clinical practice,” the researchers wrote, later concluding that the results “support a call for innovations in how OMT is incorporated into interventional strategies and for improving the translation of clinical evidence into practice.” – by Brian Ellis

It is a paper of some interest. It would appear to be disappointing that the rates of OMT were low and little affected by COURAGE trial results. However, there are significant limitations beyond those reported. The institutions reporting were not constant. Also the purpose of the NCDR CathPCI database is primarily to examine PCI outcomes. The medications and contraindications to medications may not have been as complete or careful as one would hope. Also, while these patients did not have acute coronary syndromes, there may have been some urgency to their care, limiting ability to place patients on OMT prior to their procedures. We should be glad to see a 20% absolute increase in OMT after the procedure given that these patients generally have a length of stay of 1 day and are often not even formally hospital admissions. So, while we should not be complacent and need to do better, let us also not overestimate the problem.

– William Weintraub, MD
Cardiology Today Editorial Board member

Disclosures: Dr. Weintraub reported no relevant financial disclosures.

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