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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Recent changes in practice of elective percutaneous coronary intervention for stable angina
Bina Ahmed1, Harold L Dauerman, Winthrop D Piper
1Division of Cardiology, University of New Mexico, Albuquerque, NM 87131, USA. bahmed@salud.unm.edu
Insights
The COURAGE trial found optimal medical therapy equally effective as PCI for stable coronary artery disease. Following its publication, percutaneous coronary intervention (PCI) use for stable angina significantly declined, impacting clinical practice.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Health Services Research
Background:
- The COURAGE trial demonstrated that optimal medical therapy (OMT) alone is as effective as OMT plus percutaneous coronary intervention (PCI) for stable coronary artery disease.
- The impact of these findings on actual clinical practice patterns remained unclear.
Purpose of the Study:
- To evaluate the effect of the COURAGE trial results on the utilization of PCI for stable angina.
- To analyze trends in PCI volume before and after the publication of the COURAGE trial.
Main Methods:
- Analysis of 26,388 PCI procedures from the Northern New England Cardiovascular Disease PCI Registry (January 2006-June 2009).
- Identification of a "COURAGE-like" patient group undergoing elective PCI for stable angina on admission.
- Comparison of PCI volume trends for stable angina versus other indications before and after the COURAGE trial publication (March 2007).
Main Results:
- A statistically significant decrease in overall PCI volume was observed post-COURAGE publication, with a peak relative reduction of approximately 16%.
- PCI for stable angina, as a percentage of all PCI procedures, decreased from 20.9% to 16.1% after the trial's release.
- A significant 26% peak decrease in PCI volume for stable angina patients was noted post-COURAGE compared to pre-COURAGE levels.
Conclusions:
- The publication of the COURAGE trial results was associated with a significant and sustained reduction in PCI use for stable angina.
- The long-term clinical outcomes for patients following this shift in practice are yet to be determined.
Background:
The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to compare optimal medical therapy alone versus optimal medical therapy and percutaneous coronary intervention (PCI) for treatment of patients with stable coronary artery disease and showed equal efficacy for optimal medical therapy with or without PCI. The impact of results from the COURAGE trial on clinical practice is unknown.
Methods And Results:
We analyzed 26 388 consecutive patients from the Northern New England Cardiovascular Disease PCI Registry who underwent PCI between January 2006 and June 2009. We identified a COURAGE-like patient group as patients who were undergoing (1) an elective procedure; (2) for an indication of stable angina; and (3) on the day of admission (ie, the date of admission was the same as the procedure date). All other PCI patients were placed in an "other indications" cohort. We compared temporal trends in overall volume in PCI for stable angina and for other indications, comparing quarterly time periods before and after release of COURAGE in March 2007. Over the study period, there was a statistically significant decrease in total PCI volume from 2064 in Quarter 1 2006 (before COURAGE) to 1708 in Quarter 3 2007 (after COURAGE) (P<0.01). These trends were sustained through June 2009, with an approximate 16% peak relative reduction in all PCI compared with before COURAGE. As a percentage of all PCI, stable angina reached a high of 20.9% before COURAGE and began to decrease immediately after publication of COURAGE in Quarter 2 2007 to 16.1% (P<0.01). Among patients undergoing PCI for stable angina, there was a significant 26% peak decrease in post-COURAGE PCI volumes compared with pre-COURAGE Quarter 1 2006 (P trend, 0.01), which was maintained through the end of the study period.
Conclusions:
Publication of results from the COURAGE trial was temporally associated with a significant and sustained decline in the use of PCI to treat patients with stable angina. The long-term impact of this change in practice on patient outcomes remains to be determined.
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