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CLINICAL RESEARCH: CORONARY ARTERY DISEASE

Optimal Medical Therapy With or Without Percutaneous Coronary Intervention in Older Patients With Stable Coronary Disease

A Pre-Specified Subset Analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) Trial

Koon K. Teo, MB, BCh, PhD^_*, Steven P. Sedlis, MD, William E. Boden, MD^,_*, Robert A. O'Rourke, MD, David J. Maron, MD^||, Pamela M. Hartigan, PhD^¶, Marcin Dada, MD^#, Vipul Gupta, MBBS, MPH, John A. Spertus, MD, MPH^_**, William J. Kostuk, MD, Daniel S. Berman, MD, Leslee J. Shaw, PhD, Bernard R. Chaitman, MD^||||, G.B. John Mancini, MD^¶¶, William S. Weintraub, MD^## COURAGE Trial Investigators

^_* McMaster University Medical Center, Hamilton, Ontario, Canada
Veterans Affairs (VA) New York Harbor Health Care System and New York University School of Medicine, New York, New York
VA Western New York Health Care System, Buffalo General Hospital, and the University at Buffalo, Buffalo, New York
VA South Texas Health Care System, San Antonio, Texas
^|| Vanderbilt University Medical Center, Nashville, Tennessee
^¶ VA Cooperative Studies Program Coordinating Center and VA Connecticut Health Care System, West Haven, Connecticut
^# Hartford Hospital, Hartford, Connecticut
^_** Mid America Heart Institute, Kansas City, Missouri
London Health Sciences Centre, London, Ontario, Canada
Cedars-Sinai Medical Center, Los Angeles, California
Emory University School of Medicine, Atlanta, Georgia
^|||| St. Louis University, St. Louis, Missouri
^¶¶ University of British Columbia, Vancouver, British Columbia, Canada
^## Christiana Care Health System, Newark, Delaware

Manuscript received April 24, 2009; revised manuscript received July 8, 2009, accepted July 13, 2009.

^_* Reprint requests and correspondence: Dr. William E. Boden, Division of Cardiology, Buffalo General Hospital, 100 High Street, Buffalo, New York 14203 (Email: wboden{at}kaleidahealth.org).

Objectives: Our aim was to access clinical effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) in older patients with stable coronary artery disease (CAD).

Background: While older patients with CAD are at increased risk for cardiac events compared with younger patients, it is unclear whether PCI may mitigate this risk more effectively than OMT alone or, alternatively, may be associated with more complications.

Methods: We conducted a pre-specified analysis of outcomes in stable CAD patients stratified by age and randomized to PCI + OMT or OMT alone in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial.

Results: A total of 1,381 patients (60%) were <65 years of age (mean 56 ± 6 years) and 904 patients (40%) were 65 years of age (mean 72 ± 5 years). Achieved treatment targets for blood pressure, low-density lipoprotein cholesterol, adherence to diet and exercise, and angina-free status did not differ by age or treatment assignment. Among older patients, there was a 2- to 3-fold higher death rate, but similar rates of myocardial infarction, stroke, and major cardiac events compared with younger patients. The addition of PCI to OMT did not improve or worsen clinical outcomes in patients 65 years of age during a median 4.6 year follow-up.

Conclusions: These data support adherence to American College of Cardiology/American Heart Association clinical practice guidelines that advocate OMT as an appropriate initial management strategy, regardless of age. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657 [ClinicalTrials.gov] )

Key Words: percutaneous coronary intervention • optimal medical therapy • coronary artery disease

Abbreviations and Acronyms   ACC = American College of Cardiology   ACS = acute coronary syndromes   AHA = American Heart Association   BMI = body mass index   CAD = coronary artery disease   MI = myocardial infarction   OMT = optimal medical therapy   PCI = percutaneous coronary intervention

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J. Am. Coll. Cardiol. 2009 54: A26. [Full Text] [PDF]