McMaster University

McMaster University

Faculty of
Health Sciences

Common procedure to unblock arteries not necessarily best

Published: March 27, 2007
Koon Teo
Dr. Koon Teo, professor of medicine at McMaster University

One of the most common procedures used to repair partially blocked arteries to the heart is no more effective in preventing future heart attacks than medical therapy that involves the use of various drugs and lifestyle programs, according to research presented today.

Percutaneous coronary interventions (PCI), which involves using a catheter to insert a balloon that is inflated to clear a blockage from a coronary artery, was introduced more than 30 years ago and is performed more than one million times a year in the United States alone.

But a study that compared the health outcomes of patients with coronary artery disease who had PCI as well as "optimal medical therapy" (OMT), to patients who were treated with OMT only, shows no difference in the incidence of future heart attacks or other cardiac events.

The results of the study were presented today at the American Cardiology Conference in New Orleans, and were simultaneously published in the New England Journal of Medicine.

The Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial enrolled 2,287 patients at 50 hospitals in the United States and Canada. They suffered from chronic chest pain (angina pectoris) and had at least a 70 percent blockage of one or more coronary arteries. Study participants were randomized into two groups: those who had PCI and OMT, and those treated with OMT alone.

The trial was led in the U.S. by Dr. William E. Boden at the State University of New York at Buffalo School of Medicine and Biomedical Sciences, and in Canada by Dr. Koon Teo, professor of medicine at McMaster University.

The study followed patients for a period of up to seven years. Results showed a similar rate of death, heart attack or stroke between the two groups, as well as similar rates of hospitalization for acute coronary syndrome. Both the PCI and OMT groups experienced marked improvements in their angina but the one benefit found for the PCI group was less angina.

OMT includes guideline-driven intensive treatment with medicines such as aspirin, statins, anti-platelets, nitrates, ACE inhibitors, beta-blockers and calcium channel blockers, as well as lifestyle programs such as smoking cessation, exercise and weight control and nutrition counselling.

"Conventional wisdom would indicate that PCI and OMT together would be superior to OMT alone. Indeed, that was our initial hypothesis," said Boden, lead investigator of the study, which was supported by the Department of Veterans Affairs and the Canadian Institutes of Health Research. "But results of the COURAGE trial demonstrate that two treatments are not always better than one."

"This study shows that in patients who have partially blocked coronary arteries and angina, PCI may not always be necessary", said Teo, "provided they receive intensive optimal medical therapy."

Most of the patients in the trial were male and exhibited several risk factors for heart disease, such as smoking, hypertension and high cholesterol. Risk factors such as diabetes, high cholesterol levels and high blood pressure were treated intensively in all patients in the trial, regardless of whether they received PCI.

Dr. Peter Liu, Scientific Director of the Canadian Institutes of Health Research Institute of Circulatory and Respiratory Health, said the COURAGE trial provides new information on potential therapies for heart disease.

"As cardiovascular disease is the leading cause of death in Canada, studies like COURAGE are essential in the search for the best regimen possible," he said.

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