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Health Status and Angina Relief Results from COURAGE

For patients with chronic CAD, an observed advantage of early PCI over initial medical management was small and transient.

The COURAGE trial included 2287 patients with stable coronary artery disease randomized to receive primary percutaneous coronary intervention plus optimal medical therapy or optimal medical therapy alone. In March 2007, the COURAGE investigators reported no significant between-group differences in the risk for death or MI at a median follow-up of 4.6 years (JW Cardiol Mar 26 2007). The present analysis compares the effects of the two treatment strategies on angina relief and general health status.

In both groups, the percentage of patients who were free of angina increased markedly within 1 month of enrollment. Through 24 months, the proportion of angina-free patients was slightly but significantly higher in the PCI group than in the medical-therapy group; however, at 36 months, this difference was nonsignificant. The proportion of patients with clinically significant improvement in physical function, angina frequency, and quality of life was significantly higher in the PCI group for the first 6 months but not thereafter. In both groups, patients with the most severe angina at baseline improved the most.

Many patients in the medical-therapy group eventually underwent PCI during the trial. In the subgroup of 895 patients who did not cross over to PCI in the first 3 months, improvement during this period was similar to that in the entire medical-therapy group. The pattern of the findings persisted in a variety of analyses that differed in their approach to missing data and deaths. General health status at 36 months, measured by the RAND 36-item health survey, was similar in the two groups.

Comment: These findings provide evidence of a very modest early advantage of PCI for patients with stable coronary disease. This group may represent up to one third of all PCIs performed, according to the authors of a related editorial. However, the significant between-group differences found in early follow-up were generally small and of questionable clinical importance. This study will fuel the debate about the best therapeutic approach to these patients. Although the trial was conducted before drug-eluting stents came into widespread use, its results suggest that elective PCI should be reserved for patients with the most severe symptoms.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology August 13, 2008

Citation(s):

Weintraub WS et al. for the COURAGE Trial Research Group. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med 2008 Aug 14; 359:677.

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• Medline abstract (Free)

Peterson ED and Rumsfeld JS. Finding the courage to reconsider medical therapy for stable angina. N Engl J Med 2008 Aug 14; 359:751.

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