Strategies in stable ischemic heart disease: lessons from the COURAGE and BARI-2D trials
Stanley F Fernandez1, William E Boden
1Division of Cardiovascular Medicine, University at Buffalo and Buffalo General Hospital, University at Buffalo School of Medicine, State University of New York at Buffalo, Buffalo, NY, USA.
Insights
Optimal medical therapy (OMT) is recommended for most patients with stable ischemic heart disease (SIHD). Early revascularization offers no mortality benefit over OMT alone, but CABG may reduce heart attacks in diabetic patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Debate exists on optimal treatment for stable ischemic heart disease (SIHD).
- Conflicting data from trials and meta-analyses on early revascularization benefits.
- Two major trials, COURAGE and BARI-2D, compared OMT with early revascularization.
Purpose of the Study:
- Review findings of COURAGE and BARI-2D trials.
- Discuss trial strengths, limitations, and general applicability.
- Evaluate revascularization strategies versus optimal medical therapy (OMT) in SIHD.
Main Methods:
- Review of two multicenter randomized trials: COURAGE and BARI-2D.
- COURAGE: SIHD patients randomized to early percutaneous coronary intervention (PCI) + OMT vs. OMT alone.
- BARI-2D: Diabetic patients randomized to early revascularization (PCI or CABG) + OMT vs. OMT alone.
Main Results:
- Early PCI + OMT did not reduce mortality or major cardiovascular events compared to OMT alone in SIHD.
- BARI-2D subset analysis: Early coronary artery bypass grafting (CABG) reduced nonfatal myocardial infarction vs. OMT.
- OMT alone is a cost-effective initial strategy for most SIHD patients.
Conclusions:
- For most SIHD patients, initial management with OMT is recommended.
- Revascularization is reserved for severe or refractory symptoms despite OMT.
- Early CABG may be considered for diabetic patients with extensive coronary artery disease.
Abstract:
There is a continuing debate regarding the most effective strategy for treating stable ischemic heart disease (SIHD). Conflicting data have emerged from several small, randomized controlled trials and meta-analyses regarding the benefits of early revascularization in SIHD. Two recent multicenter, randomized trials, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial and the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI-2D) trial, compared two management strategies in SIHD-an initial conservative approach with optimal medical therapy (OMT) versus a strategy of early revascularization in combination with OMT. COURAGE randomized SIHD patients who were candidates for percutaneous coronary intervention (PCI) to either a strategy of early PCI in combination with OMT or OMT alone, whereas BARI-2D randomized diabetic patients with coronary artery disease to either early revascularization (PCI or coronary artery bypass surgery [CABG]) versus OMT. This review examines the principal findings of these trials, with discussion of their strengths, limitations, and applicability to the general population. The results support the hypothesis that in patients with SIHD, early revascularization with PCI in combination with OMT is not superior to OMT alone in reducing mortality and other major cardiovascular events. Subset analysis from BARI-2D did suggest that early CABG, although it did not reduce mortality, significantly reduced the rate of nonfatal myocardial infarction compared with an initial OMT approach. Based on these data, the majority of patients with SIHD should be managed initially with medical therapy, a strategy that is also the most cost effective. Revascularization can be considered for patients with severe or refractory symptoms despite a trial of medical therapy. For diabetic patients who have extensive coronary artery disease, early revascularization with CABG may be reasonable.
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