Most With Stable CAD Go Straight to PCI, Skip Optimal Medical Therapy



Contrary to clinical practice guidelines and simple logic, most patients with stable coronary artery disease are not given optimal medical therapy before undergoing percutaneous coronary intervention, according to results of an observational registry study published in the May 11 issue of JAMA.

Even after "the most definitive randomized trial" comparing the two approaches concluded in March 2007 that PCI is no more effective than optimal medical therapy at preventing MI or death in stable CAD, there was little change in this pattern, said Dr. William B. Borden of the departments of medicine and public health at Weill Cornell Medical College in New York, and his associates.

"Some physicians may believe that stents are better than medical therapy for patients with stable CAD, even in the absence of evidence to support this view," they noted.

Dr. Borden and his colleagues assessed practice patterns regarding the use of optimal medical therapy before and after PCI using data from the national CathPCI Registry. They examined a 19-month interval before publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial results (N. Engl. J. Med. 2007;356:1503-16) and a 24-month period afterward, to determine whether physicians adopted those findings into clinical practice.

The study population comprised 467,211 patients treated at 1,013 U.S. hospitals, which constituted about 28% of the total CathPCI population during the study period. Optimal medical therapy was defined as being prescribed aspirin, a beta-blocker, and a statin before PCI and being prescribed aspirin or thienopyridine, a beta-blocker, a statin, and an ACE inhibitor or angiotensin receptor blocker after PCI, or having specific contraindications to these medications.

Overall, fewer than half of PCI patients – 45% – received optimal medical therapy before undergoing PCI. Current guidelines recommend maximizing medical therapy because that often relieves symptoms, obviating the need for PCI.

The rates of optimal medical therapy increased only slightly after publication of the COURAGE results, from 43% to 45%. This increase "was of little clinical significance," the investigators said (JAMA 2011:305:1882-9).

Clinicians did use PCI as an opportunity to improve patients’ medical regimens throughout the entire study period. The proportion of patients who received optimal medical therapy after PCI was significantly higher, at 65%, than that before the procedure (42%). However, the proportion of patients receiving optimal medical therapy after PCI did not change significantly after publication of the COURAGE results (66%), compared with before (64%), they noted.

"The responsibility of administering the full complement of medical therapy, however, ought not to be placed solely on the interventional cardiologist, but rather [ought to] be a shared responsibility with the primary physicians caring for the patient," Dr. Borden and his associates said.

"Our findings suggest a promising possibility of developing better care through better collaboration. Although patients with stable CAD who are receiving PCI are often only in the hospital for less than 24 hours, multidisciplinary teams could use this time to optimize a patient’s medical regimen, use the ‘teachable moment’ of an invasive procedure to impart to patients the importance of medication adherence, and engage the patient in a program that supports the transition of care so that important medications are implemented," they said.

This study was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry, with additional support from Weill Cornell Medical College and the Agency for Healthcare Research and Quality. Dr. Borden reported ties to Kowa Company.

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