Cardiac Bypass Surgery and Percutaneous Coronary Intervention (PCI)

• CABG and PCI
  • Coronary Artery Bypass Surgery
  • Percutaneous Coronary Intervention

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• PCI- For Stable Coronary Artery Disease
  • COURAGE- PCI vs Medical Therapy
  • Routine PCI not always cost-effective.
  • From the ASEANZ 2009 meeting

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• PCI- For Unstable Coronary Artery Disease
  • To be added

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• PCI vs CABG for multi-vessel disease
  • To be added

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Stable Coronary Artery Disease

COURAGE

Percutaneous Intervention Does Not Reduce Risk of Myocardial Infarction or Death Compared to Medical Therapy

The aptly titled COURAGE trial was published in the New England Journal of Medicine in 2007. The trial randomised patients to initial medical therapy vs percutaneous intervention.

The publication of the trial was followed by a chorus of protest from some sections of the interventional cardiologist community maintaining that their members had never meant to imply that there was reduction of coronary events in patients with stable disease after percutaneous intervention with stents!

The reality is, as many would agree, that the threshold for percutaneous intervention has fallen markedly. Immediate percutaneous intervention after angiograpy was increasingly accepted as the norm. The advent of drug eluting stents had been arguable followed by even further increase of intervention rates in stable patients with minimal symptoms or in those that had not had a trial of medical therapy.

The prospective and randomised COURAGE trial confirmed analysis of observational studies- there is not reduction in rates of myocardial infarction or death after percutaneous intervention when patients have "stable" angina.

The COURAGE trial enrolled:

• more than 2000 patients.
• patients with stable or recently unstable angina
• patients with symptoms of angina with more than 50% having CCS class II or III angina.
• patients with single or multi-vessel disease (more than two-thirds had double or triple vessel disease)
• patients with proximal LAD disease (approximately one-third had proximal LAD disease)

The COURAGE trial found- after a median followup of 4.6 years,

• there was no reduction in rates of non-fatal myocardial infarction or death (19.0% and 18.5% in the PCI and medically treated groups, respectively).

Hitesh Patel
Cardiologist
February, 2008

Reference
Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-16.