“The reasons for this need to be better understood, including the possible role of low medication adherence rates that have been found in other studies,” comment the authors of the report in Circulation online March 22.
Dr. Edward L. Hannan, with the State University of New York in Rensselaer, and colleagues point out that the COURAGE trial found that PCI with optimal medical treatment did not improve outcomes in stable CAD patients compared with optimal medical care alone, but little is known about how such patients fare when they are not involved in a clinical trial.
To investigate this issue, the team analyzed information from New York State’s Cardiac Diagnostic Catheterization Database on 9586 patients with stable CAD, 8486 of whom (88.5%) underwent PCI along with routine medical treatment. Propensity scoring matched 933 patients who received routine medical therapy only to the same number of very similar PCI patients.
At 4 years, PCI patients compared to medical patients had significantly lower rates of the composite endpoint of mortality or MI (16.5 % vs. 21.2%, p=0.003), mortality (10.2% vs. 14.5%, p=0.02), MI (8.0% vs. 11.3%, p=0.007) and subsequent revascularization (24.1% vs. 29.1%, p=0.005), the investigators found.
Only in patients younger than 65 and those with single vessel disease was mortality similar with either routine medical treatment alone or with PCI and routine medical care, according to the report.
Noting the need to examine the reason these findings, Dr. Hannan and colleagues conclude, “An RCT in which patients are randomized to PCI and MT (medical treatment) without efforts to guarantee optimal MT would serve as a definitive test of how patients in routine medical practice fare with each of the interventions.”
The author of an accompanying editorial discusses the broad evidence on the best treatment for stable CAD patients, and several shortcomings of the current study.
Dr. William E. Boden, with the Samuel S. Stratton VA Medical Center in Albany, New York, points out the “highly disproportionate” rate of PCI versus routine medical treatment (RMT), and suggests that “the fact that only ~10% of patients received RMT alone raises serious concerns about the validity of the data and the degree to which these highly-selected results can be generalized to the totality of CAD patients in the ‘real world’.”
Noting the extensive evidence that optimal medical therapy is not inferior to PCI in stable CAD patients, he concludes. “Embracing optimal medical therapy in a “PCI-first” practice culture takes enormous effort, dedication, and commitment but, in the end, its benefits are well worth the struggle.”