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Does PCI Improve Survival and Prevent MI in Stable CAD?

No such benefit was found in the COURAGE trial of PCI versus optimal medical therapy alone.

Percutaneous coronary intervention (PCI) has survival and MI-prevention benefits in patients with acute coronary syndromes (ACS), and it reduces angina frequency and improves exercise tolerance in patients with stable coronary artery disease (CAD). Do the survival and MI-prevention benefits extend to stable CAD patients?

In the COURAGE trial, 2287 patients (mean age, 62; 85% men; 33.5% with diabetes) were randomized to PCI plus optimal medical therapy or to optimal medical therapy alone. All patients had either 70% stenosis with objective evidence of ischemia or 80% stenosis with classic angina. Patients with a markedly positive stress test or a left ventricular ejection fraction (LVEF) <30% were excluded. Enrolled subjects had a mean LVEF of 61%.

Of the PCI group, 94% received stents (97% were bare-metal), and 41% received more than one stent. Both groups had high rates of receiving optimal medical therapy and of adhering to healthful dietary regimens, regular exercise, and smoking cessation; they each achieved mean LDL-cholesterol levels of just above 70 mg/dL within 5 years. Median follow-up was 4.6 years (maximum, 7 years); about 9% of patients were lost to follow-up.

The incidence of death or MI (the primary outcome) was similar in the two groups (PCI, 19.0%; medical therapy alone, 18.5%), as were the incidences of hospitalization for ACS (12.4% and 11.8%, respectively) and stroke (2.1% and 1.8%). The PCI group had a significantly lower revascularization rate during follow-up (21% vs. 33% with medical therapy alone), and they had a significant advantage in freedom from angina at 1 year (66% vs. 58%) and 3 years (72% vs. 67%) but not at 5 years (74% vs. 72%).

Comment: In patients with stable CAD, the roughly 5-year incidence of death or MI was similar with a PCI strategy and one of optimal medical therapy alone, although PCI showed some advantage in relieving angina. As the editorialist notes, fewer than 10% of screened patients were eligible for this trial, and fewer than 75% of eligible patients were enrolled, raising questions about the generalizability of the results. On balance, the data highlight the benefits of optimal medical therapy in patients with stable CAD who do not have stress-test results that suggest high risk for events. The findings confirm the current guideline recommendation that PCI can be safely deferred in these patients.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology March 26, 2007

Citation(s):

Boden WE et al. for the COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007 Mar 27; [Epub ahead of print]. (http://content.nejm.org/cgi/content/short/NEJMoa070829)

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• Medline abstract (Free)

Hochman JS and Steg PG. Does preventive PCI work? N Engl J Med 2007 Mar 27; [Epub ahead of print]. (http://content.nejm.org/cgi/content/short/NEJMe078036)

• Original article (Subscription may be required)
• Medline abstract (Free)