March 27, 2007 -- New Orleans -- Results of the COURAGE trial,
presented today at the American College of Cardiology Annual Scientific Session,
unlikely to alter the approach that interventional cardiologists take in
treating most patients with chronic stable angina, say leaders from the
Society for Cardiovascular Angiography and Interventions (SCAI), the leading
professional society for interventional cardiologists in the United States.
Percutaneous coronary intervention (PCI) typically involves placement of a
stent to relieve a blockage within a coronary artery and thus relieve the
symptom of chest pain. Preliminary results of the Clinical Outcomes
Utilizing Percutaneous Coronary Revascularization and Aggressive
Guideline-Driven Drug Evaluation (COURAGE) trial, announced during a press
conference yesterday, focused on the finding that, when added on top of an
optimal drug program, PCI reduces neither mortality nor heart attack in
patients with chronic stable angina.
Chronic stable angina is a condition that causes patients to experience
symptoms such as chest pain and shortness of breath when engaging in various
levels of activity. Data from the landmark Framingham Heart Study have shown
that these patients have an average annual mortality of only 4 percent,
making it difficult for any therapy to show a substantial improvement.
" Patients with chronic stable angina represent a minority of those treated
by interventional cardiologists, perhaps up to 30 percent," said SCAI
President Gregory J. Dehmer, MD. "More frequently, patients treated by
interventional cardiologists have heart attacks or another serious problem
called unstable angina. The COURAGE study did not evaluate this type of
patient; however, the study's investigators acknowledged that PCI is the
best therapy for patients suffering heart attack."
It is important to put the results of the COURAGE study into the proper
perspective, stressed Dr. Dehmer. "We are concerned that many seem to be
interpreting this study as part of a huge battle among cardiologists that
will shift therapy in a dramatic way, but I don't really see it shaping up
that way. Although PCI is life-saving in the setting of a heart attack, it
has never been promoted in any of the national treatment guidelines as
saving lives or preventing heart attacks in patients with chronic stable
angina. Although it is tempting to pick apart the COURAGE trial for its
flaws, and there are some, doing so would remove the focus from how the
results can best be used to improve patient care," said Dr. Dehmer.
SCAI leaders view the COURAGE study results as a contemporary update of how
much the treatment of coronary artery disease has advanced, whether by use
of medications, PCI, or both. While some patients with chronic stable angina
can be managed safely with medications, such therapy may not be the best fit
for every patient.
" The right therapy for an elderly patient with a limited lifestyle may not
work for a younger, more active individual. It is always challenging to
extrapolate trial results to the 'real world,' and real-world questions
about individual patients' ability to comply with aggressive drug therapies
apply here," said Dr. Dehmer. "We agree that medical therapy has come a long
way, but a simple question reveals the challenges that accompany relying too
heavily on medications - The last time you got a prescription for a 14-day
course of antibiotics, did you take every pill on schedule? Or did you stop
when you started feeling better?"
Given the COURAGE findings, SCAI is reminding physicians to talk in detail
with their patients and clearly explain therapeutic goals, whether the
treatment is medical therapy or PCI. "I feel certain that most
interventional cardiologists already do this, but it is worth repeating.
Patients with chronic stable angina should understand the purpose of
whatever treatment is being proposed and know that they do have options -
both good options - for the treatment of their chronic stable angina," said
Headquartered in Washington, DC, the Society for Cardiovascular Angiography
and Interventions is a 3,700-member professional organization representing
invasive and interventional cardiologists in 70 nations. SCAI's mission is
to promote excellence in invasive and interventional cardiovascular medicine
through physician education and representation, and advancement of quality
standards to enhance patient care. SCAI's annual meeting has become the
leading venue for education, discussion, and debate about the latest
developments in this dynamic medical specialty. SCAI's next annual meeting
will be in Orlando, FL, May 9-12, 2007.
Source: Society for Cardiovascular Angiography and Interventions
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