Monday, March 26, 2007

No Stent? It'll Take COURAGE.

“Ms. Jones, you know that chest discomfort you get after you pick up your mail and walk up the driveway back to your home?”


“Well I’ve got good new and bad news.”

“What’s that?”

“First the bad news: your angiogram demonstrated you’ve got 80% blockages in two of your three arteries on your angiogram today.”

“What’s the good news?”

“Well, according to this important trial today I heard about at the American College of Cardiology Meeting, we’ve just got to put you on five medications, and ask you to take it easy for a while, and you’re likely to do fine.”

“But what about those 80% blockages, doctor? Isn’t that pretty close to 100%? And if it gets to 100%, what happens?”

“Well, I suppose you could have a heart attack. But this study I read about today suggested the same thing might happen if you get a stent, too.”

“But doctor, aren’t you going to DO ANYTHING about my blockages?”

“Yes, Ms. Jones, I’m going to put you on all of these pills – they’re good for your heart.”

“But I don’t like taking pills, doc. Isn’t there anything you can do?”

“This is what I’d recommend right now, Ms. Jones.”

“But all of my friends have gotten a stent, and they seem pretty happy.”

“ I understand, Ms. Jones, but our thinking about this is changing rapidly…”

“What would you have done yesterday?”


“Yes doctor, honestly.”

“Probably given you the stents.”

“I think I’ll get a second opinion.”

“I understand, Ms. Jones. Don’t forget to get those prescriptions I wrote for you.”

* * *

Potential implications from today’s COURAGE trial?

  • Potential lost interventional cardiology revenue, but many more visits for non-invasive cardiologists to assess adequacy of medical therapy and more stress test/nuclear imaging tests over time.

  • Increased drug company revenues, especially manufacturers of statin drugs.

  • Possibly lower investment in 64-slice CT scans knowing that medication therapy is the preferred first-line of therapy in patients with asymptomatic coronary disease.

But what should be remembered before the doomsday predictions for the stent makers take hold, doctors will have a difficult time always recommending stents for the above reasons – especially when 35,539 patients who were assessed for eligibility in the trial, 32,468 were excluded for a variety of reasons. Remember, patients with severe ventricular dysfunction, clinical instability, or very early ST-segment depression or hypotension on stress testing were excluded from the trial. Certainly in a carefully selected patient population, these results are important, but there are still plenty of patients out there hwo will continue to need the services of an interventional cardiologist.

Will bypass be similarly affected by reduced referrals? Very likely.

What is certain: a seismic tremor was felt in the cardiology community today…


References: New England Journal of Medicine COURAGE Trial

NEJM Accompanying Editorial


scalpel said...

The trouble I see is that stent patients usually end up on a bunch of those same medications anyway. It generally isn't an either-or proposition.

I'm glad you reviewed the limitations of the study. That's something that didn't make the news.

Anonymous said...

If it were me with 80% blockage, please please give me the stent! How bout you?

Dr. A said...

Agree with scalpel. Good analysis of the study limitations.

coaster1robert said...

I could see bypass surgery being increased,over the news in the big easy.
2-years ago i found out that two of my three arteries were blocked 80% on my heart,I had pressure on my chest,I couldn't even cut the grass,with semi-automatic mower.So basically surgeries,are still necessary,or stents anyway.

Anonymous said...

how about adding ranexa after the stent? I'm interested in your thoughts on the Merlin trial. Is the anti arryth. data important to you? Is it still considered unsafe?

Anonymous said...

The media had its day with the COURAGE results, but was it really news to anyone in the cardiology community? We always knew that with exception of Left main and 3-vessel disease (and possibly very proximal LAD) there is no mortality benefit for angioplasty. Yes, it improves symptoms, but the survival doesn't change. COURAGE just once again confirmed what we've known all along. I see it as an opportunity not to intervene and use medical therapy when you feel it's appropriate. The social and legal pressure to PCI finally will be somewhat relieved.

Anonymous said...

The commentary is a little disingenous with the "would you rather take 5 pills" and the "I don't like to take all those medicines". The COURAGE trial was maximal medical therapy + a stent vs. maximal medical therapy. The patients were on essentially the same medicines. With a stent, though, you probably get Plavix too.

So, yes the applicable population is small, but the results are not increasing drug company profits or adding more meds. It likely doesn't increase visits for monitoring and stress tests either.