Thursday, April 05, 2007

The other side of COURAGE

At the offset, I must first declare that I am an interventionist. You can also call me a "balloon lunatic" (Balloonatic....) There are more then one way to look at this trial. Looking at it overall, there seem to be a group in developed countries who do not like cardiac interventionist. The recent hoo-haa over "late stent thrombosis", the chorus following it and the current "Courage" (with the chorus following it), quickly unmask those who have a bone to pick with "you interventionist who do too many unnecessary angioplasties".

If I can look at it from an "unbiased" veiwpoint, the "Courage"  trial was set up with good intentions of trying to determine the best treatment modality for chronic stable angina. Please note that we are talking about chronic stable angina. I do not think that I have to go through the whole trial design except to highlight the pertinent points. We now know (only too well) that angioplasties do not help to reduce AMI and death in people with chronic stable angina. This fact we had known for a longtime. In fact, in our guidelines, that is what is stated. That in chronic stable angina, medical treatment is the treatment of first choice. That angioplasty should be considered for those patients whose chest pains are not well controlled with medical therapy. In fact, that is what we do. All patients with chest pains, before they are taken to the cath. lab., are started on medical therapy first. The difference is in how aggressive we medicate them before an angioplasty decision is made.

Where it gets ugly is that there are some out there, who do mass screening checks (usually using 64-MSCT) at 9 am , see what is conceived as a stenosis, convince the patient that he is going to die (when he is essentially without symptoms) and schedule the angiogram / angioplasty at 1.30pm. This is the group that perhaps "Courage" is hopefully trying to address.

Now back to "Courage". It is worthwhile to remember that one-third of patients on the medical therapy arm, cross over to angioplasty, telling us that angioplasty must be better. Also remember that neither method ( medical treatment or angioplasty ) could control the anginas 100%. Courage also did not include patients with heart attacks and unstable angina, the two subsets that we are sure where angioplasties will reduce AMIs and death. It is also good to remember that this study was not blinded and so there is some play of physician preference (unwritten, but inevitable). Also this study did not use the current day preferred drug-eluting stents.

Well, all in all, it looks like nothing much has changed for balloon-lunatics, except perhaps for "wannabes imitators" who do screening 64-MSCTscans on assymptomatic patients and react (oculo-stenotitic reflex) with angioplasty for all the lesions, if any, without ischemia provoking test (if they believe in evidence base medicine) will not be doing them, in the light of "COURAGE". But then, if they are doing mass screening with 64-MSCT scans, they are not much evidence based anyway, so they will not be affected. Basically, despite "COURAGE" life goes on. Nothing much has changed, as always.

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