UPDATES ON "COURAGE " . A TRIAL OF PCI Vs OMT. PCI IS NO BETTER THAN OMT.

Dr Bill Boden and group published the COURAGE Trial in NEJM 2007 and we wrote about it in the blog then. The COURAGE is a trial comparing OMT ( optimal medical therapy ) against PCI ( percutaneous coronary intervention) in patients with chronic stable angina. Basically, the trial findings were that except for patients with severe angina, PCI did not offer any advantage, and PCI obviously does not offer any advantage if you do not have chest pains at all. PCI definitely does not prolong survival and obviously does not prevent a heart attack. In our local context, it would mean that all those cardiac scan centers, who do cardiac checkups with a 64MSCT angiogram, sees a stenosis, and "frightens " patients to PCI, have no medical basis, and the general public must know that.
This trial had been hotly debated in many medical and cardiac meetings. All those aggressive interventionist tried to justify their " oculo-stenotic-dilating " reflex, and all the conservative cardiologist will use COURAGE to say that there is no medical benefit, but may it fact be an economic benefit for the operator.
Well, health economist in the USA have now analysed the COURAGE data, out to 36 months and found that after 4 years of follow-up, those patients who had OMT still did just as well. Those who had PCI done, slowly lost their initial advantage, in terms of angina relieve, and their angina scores after 4 years were no different from the OMT arm ( see table ). Their findings were published in the Aug 14th issue of the NEJM.

Follow-up time, mo	PCI + OMT	OMT	p
3	85	80	<0.001>
12	87	84	0.003
24	89	86	0.002
36	89	88	0.37

We will continue to teach that in patients with chronic stable angina and in patients with asymptomatic CAD, PCI holds no advantage over OMT, neither in the short term, nor out to 4 years and I dare say, for the long term. Medical angioplasty ( the use of medication to stabilise the plaque ) is still the best thing to do for your patients.
I do not think that this small piece will stop all the cardiac scan centers to continue to do 64MSCT coronary angiogram( with all the radiation hazards for the unsuspecting patients ) and should they see any stenosis, to proceed on with PCI, for it many ways, they are " dilating for their bread ".