COURAGE: Quality-of-life benefit with PCI modest, short-lived

18 August 2008

MedWire News: Percutaneous coronary intervention (PCI) on top of optimal medical therapy provides greater angina relief than optimal medical therapy alone, but the benefits are modest and short-lived, according to COURAGE data.

The COURAGE (Clinical outcomes utilizing revascularization and aggressive drug evaluation) trial previously demonstrated no additional mortality or cardiovascular event benefit from performing PCI on top of medical therapy in patients with stable coronary artery disease.

The findings led some to suggest that an interventional strategy is now used too readily in these patients. But interventionists have countered that the benefit of PCI lies in its ability to relieve angina and so improve patients' quality of life. The latest COURAGE analysis was set to test this theory.

The investigators assessed the 2287 patients in COURAGE for self-reported angina symptoms and related quality of life using the Seattle Angina Questionnaire at baseline, 1, 3, 6, and 12 months, and then annually.

As reported in the New England Journal of Medicine, SAQ scores were similar at baseline in each treatment group, and improved significantly from baseline in both groups by 1-3 months across all domains (p<0.001 for all).

Scores were higher in the PCI plus medical therapy than medical therapy only group for 6 to 24 months, depending on the domain. But these differences dissipated by 3 years.

Further analysis showed that a greater proportion of patients treated with PCI than with optimal medical therapy alone had clinically significant improvements in scores for physical function, angina frequency, and quality of life for the first 6 months, but these differences were no longer significant by 12 months.

Dividing patients into thirds according to severity of baseline angina revealed that those with the most severe angina symptoms at baseline benefited most from PCI.

In an accompanying editorial, Eric Peterson (Duke Clinical Research Institute, Durham, North Carolina, USA) and John Rumsfeld (University of Colorado, Denver, USA) commented: "A remarkable finding from the COURAGE study was the rapidity of improvement in health status in both treatment groups. This should serve as encouraging news to patients with coronary disease."

They also wrote: "The courage trial redefines the contemporary roles of optimal medical therapy and PCI in the management of patients with stable angina. Rather than one victor, COURAGE demonstrates that both treatment strategies can have a profoundly positive effect on patients' health status and suggests complementary roles - optimal medical therapy as first-line therapy, with PCI reserved for patients who do not have a response or who have severe baseline symptoms."

N Engl J Med 2008; 359: 677-687