This editorial comment was written by SOLACI.ORG and is based on an original article by Medscape which can be accessed free of charge at the bottom of this page.
COURAGE patients (Patients in the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) who crossed from the optimal medical treatment branch to the revascularization branch within one year of randomization were more likely to present significant angina that affected their quality of life and were also more likely to be dissatisfied with the treatment and the health system in which they found themselves. These results were recently published in Circulation: Cardiovascular Quality and Outcomes.
No less important is the fact that crossing from optimal medical treatment to the revascularization branch was not associated with an increased risk of death or MI compared with patients who received early revascularization, although typically the symptoms and quality of life were worse in the optimal medical therapy group during that first year. With that information the author of the article, (Dr John Spertus), believes that we are better able to identify patients who require immediate revascularization which do not change hard end points. This is something that interventionists have argued for a long time. COURAGE has been criticized for allowing this crossover, (one third of the patients were crossed to follow up), and maybe this is the reason that no differences are observed in the hard end points. But critics say it is probable that critical patients are those who crossed within the first year, these were the ones that really could not be treated with medication only, the rest could be explained by the progression of the disease.
Of the 1,168 patients randomized to medical treatment, “only” 16% were crossed within the first year. The most important predictors of early revascularization were health status and the health system where they were assisted. For example, for patients treated in Canada were 37% more likely for early revascularization than those treated under the Veteran’s health system. Probably in the first system patients were more likely to express their symptoms and to make it clear to doctors that, despite optimal medical treatment, they were not satisfied and continued to feel limited.
This work does not have enough power to reach definitive conclusions but it seems clear that there are no differences in hard points such as death or myocardial infarction between the two strategies. However, we must be aware of the symptoms that patients report to provide adequate revascularization when (relatively common) medical treatment is not enough.
SOLACI.ORG