Medical Treatments Best First-Line of Defense for Stable Coronary Disease

< Mar. 28, 2007 > -- Percutaneous coronary intervention (PCI) plus optimal medical therapy does not improve outcomes in patients with coronary artery disease, compared with optimal medical therapy alone, according to study results presented at the 56th Annual Scientific Session of the American College of Cardiology in New Orleans.

The study will be published in the New England Journal of Medicine.

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial, conducted by the Cooperative Studies Program of the US Department of Veterans Affairs (VA) and the Canadian Institutes of Health Research (CIHR), was a randomized, controlled study involving 2,287 patients with stable coronary artery disease.

Most of the study participants were Caucasian males, with an average age of 62, who had at least one coronary artery that was more than 70-percent blocked.

The study participants experienced regular chest pain (angina) at least several times per week. About 38 percent had a history of heart attack, 33 percent had diabetes, 71 percent had high cholesterol, and 67 percent had high blood pressure.

Optimal Medical Therapy for Both Groups, PCI for Half of Study Participants

All participants received optimal medical therapy (OMT), which consisted of multiple medications - including medications to lower blood pressure and cholesterol and prevent clots - and lifestyle programs for smoking cessation, physical activity, and nutrition.

Half the participants also underwent percutaneous coronary intervention, a procedure in which an interventional cardiologist clears coronary plaque by inflating a small balloon inside a blocked artery . Nearly all of the PCI recipients (93 percent) also had a stent, a wire-mesh tube, placed inside to help keep the affected artery open.

Because drug-eluting stents, which are coated with medications that help prevent scarring, were not approved until the trial was nearly completed, only 31 COURAGE patients received this type of stent. But studies have shown little difference between coated and non-coated stents in their ability to prevent heart attacks and deaths.

Results Similar for Both Groups

At a median follow-up of almost five years, the rates of death, nonfatal heart attack, stroke, and hospitalization for heart disease were the same in the two study groups: those who received only OMT, and those who received PCI plus OMT.

There were also no differences between the groups in cholesterol levels, blood pressure levels, or blood-sugar control. The groups also made lifestyle changes at similar rates: After five years, 75 percent of patients in both groups were following the recommended diet, and about 40 percent were getting regular exercise. The PCI group was more likely to report relief from angina throughout most of the follow-up period, but this difference disappeared over five years of follow-up.

"People assume that once you have PCI, it's curative," says first author and presenter Dr. William E. Boden. "I think the best we can say is that it's palliative." Dr. Boden is a consultant in cardiology at the Western New York VA Healthcare System in Buffalo. He is also the medical director of Cardiovascular Services for Kaleida Health, chief of cardiology for Buffalo General and Millard Fillmore hospitals, and professor of medicine and public health at the University of New York at Buffalo School of Medicine and Biomedical Sciences.

PCI Still Helpful for Many

According to Dr. Peter Liu, scientific director of the CIHR Institute of Circulatory and Respiratory Health, "The findings suggest that if a patient with heart disease is doing well, the latest available medications are very effective and there is no need for PCI."

PCI has been shown to help patients with more severe heart disease, sometimes referred to as unstable coronary disease. However, prior to COURAGE, the efficacy of PCI on improving clinical events had not been rigorously studied in patients with stable heart disease. Those with stable coronary disease have regular episodes of angina, usually due to physical exertion or stress.

Always consult your physician for more information.

What is Included in Optimal Medical Therapy?

At the top of the US Centers for Disease Control and Prevention (CDC)  list of primary risk factors for all chronic diseases are: smoking, poor nutrition, and sedentary lifestyle.

Living a healthier lifestyle can help to prevent heart disease. This includes:

• eliminating all tobacco products

• adhering to a heart-healthy diet

• following an appropriate exercise program

In addition, those with diabetes or high blood pressure need to work to control blood glucose and blood pressure in order to reduce the risk for developing or worsening heart disease.

Medications for stable coronary disease are used in conjuction with lifestyle changes to restore normal biochemical processes in the body.

Specific medication names vary greatly, so learning the general categories of medications that are known to be effective for treating stable heart disease, and the desired effects of each category of medication, helps to develop a deeper understanding of the goals of optimal medical therapy.

Categories of medications used to treat stable coronary disease may include:

• antiplatelet medications - decrease the ability of platelets in the blood to stick together and cause clots. Aspirin is one example of antiplatelet medication.

• antihyperlipidemics - lower lipids (fats) in the blood, particularly low density lipid (LDL) cholesterol. Statins are a group of lipid lowering medications.

• antihypertensives - lower blood pressure and relax blood vessels. Angiotensin converting enzyme (ACE) medications are one example.

• antianginal medications - prevent and treat symptoms of angina. Nitrates are one example.

• beta blockers - block the harmful effects of adrenaline, thus lowering the heart rate. Lopressor is an example of a beta blocker medication.

Always consult your physician for more information.