General Medicine

Coronary artery disease (CAD), which can result in a heart attack (either unstable angina or myocardial infarction), is treated with medications, with or without the revascularization methods of angioplasty (an invasive nonsurgical procedure, also called percutaneous coronary intervention or PCI) or coronary artery bypass grafting (an open surgery). How far the cardiologist goes with treatment depends much on the severity of the individual patient's condition.

The August 14, 2008, issue of The New England Journal of Medicine published the results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. The study randomized 2,287 patients with coronary artery disease to receive either PCI with drug therapy or drug therapy alone. Clearly, PCI with drug therapy has significantly greater benefit than drug therapy alone, at least for the first 36 months. Otherwise, the benefit appears to be similar after that point. Furthermore, patients with the most severe angina (chest pain) resulting from their CAD do better after PCI with drug therapy than after drug therapy alone.

The study has two implications:

1. Patients with the most severe CAD should have PCI with drug therapy.
2. Patients with otherwise less severe CAD can do just fine on medications alone without PCI, given that the benefit is similar between the two in the long run.

Whether these are valid statements is still debatable. In medicine, it's always best for both doctor and patient to opt for the least costly and risky treatment that can achieve the greatest benefit. At the same time, one should approach it cautiously, especially with something serious like heart disease. With time, the best approach should become more clear.

Source: Weintraub, William S., et al. "Effect of PCI on Quality of Life in Patients With Stable Coronary Disease." The New England Journal of Medicine. 2008 Aug 14;359(7):677-687.