JAMA: COURAGE has barely changed medical therapy practice patterns

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Among patients with stable coronary artery disease (CAD) undergoing PCI, less than half were receiving optimal medical therapy (OMT) before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial, according to an observational study published May 11 in the Journal of the American Medical Association.

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) study, which provided OMT to all patients and demonstrated no incremental advantage of PCI on outcomes other than angina-related quality of life in stable CAD, suggested that a trial of OMT is warranted before PCI.

“It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial,” according to the authors.

Therefore, William B. Borden, MD, of Weill Cornell Medical College, Cornell University in New York City, and colleagues conducted a study to examine use of OMT before and after PCI and to evaluate whether the use of OMT changed after the publication of the COURAGE trial (March 2007).

The study included data from the National Cardiovascular Data Registry of patients with stable CAD undergoing PCI between September 2005 and June 2009. Specifically, they analyzed data from the CathPCI Registry, which is cosponsored by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions.

With these data, the researchers compared the use of OMT, both before PCI and at the time of discharge and before and after the publication of the COURAGE trial. OMT was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, beta-blocker and statin).

Among all 467,211 patients (37.1 percent before and 62.9 percent after the COURAGE trial) meeting study criteria, OMT was used in 44.2 percent of patients before PCI and in 65 percent of patients at discharge following PCI, the researchers reported.

Before PCI, OMT was applied in 43.5 percent of patients before the COURAGE trial and in 44.7 percent of patients after the COURAGE trial. The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5 percent and 66 percent, respectively.

“Our study demonstrated that less than half of patients undergoing PCI are taking OMT before their procedure, despite the guideline-based recommendations to maximize OMT and the clinical logic of doing so before PCI so that the need for additional symptom relief from revascularization can be appreciated,” the authors wrote. “Even after publication of the COURAGE trial, little change in this practice pattern was observed.”

While clinicians increased the use of OMT before discharge, with antiplatelet agents being almost universally applied, almost one-third of patients were not treated with OMT, “a pattern that also did not change after the COURAGE trial was published,” Borden and colleagues reported. “Collectively, these findings suggest a significant opportunity for improvement and a limited effect of an expensive, highly publicized clinical trial on routine clinical practice.”