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CLINICAL STUDY

Medical therapy versus coronary angioplasty in stable coronary artery disease: a critical review of the literature

^a Division of Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
^b Department of Medicine, Cleveland Clinic Florida, Fort Lauderdale, Florida, USA

Manuscript received December 8, 1999; revised manuscript received March 7, 2000, accepted April 14, 2000.

Reprint requests and correspondence to: Dr. Roger S. Blumenthal, Preventive Cardiology, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 538, Baltimore, Maryland 21287
rblument{at}jhmi.edu

The recent publication of the Atorvastatin Versus Revascularization Treatment (AVERT) trial has renewed debate on the optimal management strategy for relatively stable patients with coronary artery disease. Currently, coronary angiography and percutaneous coronary intervention are often performed in stable patients with good exercise tolerance who have not been treated with proven medications such as aspirin, statins and beta-adrenergic blocking agents in conjunction with comprehensive lifestyle modification. We review the results of prior trials comparing medical therapy with angioplasty and assess their strengths and limitations and then make conclusions about the aggregate data. Next, we describe the ongoing Clinical Outcome Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, which will be the largest of the studies comparing optimal medical therapy and percutaneous revascularization. This study will employ intensive medical management in all patients with coronary disease, and the incremental benefit of state of the art revascularization techniques in terms of clinical event reduction, quality of life issues and cost-effectiveness will be addressed. For now, aggressive medical therapy and revascularization should be viewed as complementary rather than opposing strategies. All patients with coronary heart disease should receive proven medical and lifestyle prescriptions to favorably alter the atherosclerotic process. Percutaneous revascularization without comprehensive risk factor modification is a suboptimal therapeutic strategy.

Abbreviations and Acronyms   ACIP = Asymptomatic Cardiac Ischemia Pilot trial   AVERT = Atorvastatin Versus Revascularization Treatment trial   CABG = coronary artery bypass grafting   CAD = coronary artery disease   CCS = Canadian Cardiovascular Society   CHD = coronary heart disease   COURAGE = Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial   LAD = left anterior descending coronary artery   LDL-C = low-density lipoprotein cholesterol   MASS = Medicine, Angioplasty or Surgery Study   MI = myocardial infarction   PCI = percutaneous coronary intervention   PTCA = percutaneous transluminal coronary angioplasty   RITA-2 = Second Randomized Intervention Treatment of Angina trial

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