Author + information
- Abhiram Prasad, MD⁎ ( and )
- Anthony Hilliard, MD
- ↵⁎Cardiac Catheterization Laboratory, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905
We thank Drs. Sedlis and Boden for their interest in our article in JACC: Cardiovascular Interventions (1). Although we agree that our study suggests that “COURAGE-like” results are being achieved in clinical practice, the analysis was not intended to investigate the generalizability of the trial (1,2). It is reasonable to propose that outcomes would be even better if “optimal medical therapy,” as administered in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) study, was used, though this requires additional resources to establish an intense case management approach.
We thank Drs. Sedlis and Boden for highlighting the fact that there were additional differences between our cohort and that of the trial; however, it is not possible to accurately compare the risk profiles of the 2 groups. That said, the (mean) age, one of the most important determinants of procedural risk and long-term outcomes, was 5 years greater in the Mayo Clinic cohort. Drs. Sedlis and Boden also state that a minority of our cohort had a positive stress test. This is not accurate. Thirteen percent of patients had a positive stress as the predominant indication for percutaneous coronary intervention (PCI), but other patients also had positive stress tests but this was not the primary indication for referral and therefore not included in the variable they quote. Fifty percent of our cohort had Canadian Cardiovascular Society class III/IV angina indicating that these patients had a significant ischemic burden, and thus, we do not concur with the conclusion of Drs. Sedlis and Boden that the Mayo Clinic registry and COURAGE trial cohorts were comparable with respect to their risk profile.
Differences in procedural success may, in part, have been due to the definitions used. Drs. Sedlis and Boden point out that in COURAGE, “all periprocedural MIs” were excluded. However, clinical success (equating to our procedural success) was defined as angiographic success plus the absence of in-hospital myocardial infarction (some likely to be procedural myocardial infarction in an elective PCI population), emergency coronary artery bypass graft, or death in COURAGE.
Stable coronary artery disease represents a wide spectrum of patients with heterogeneous severity of symptoms and risk. Thus, we do not support the recommendation that all patients with stable coronary artery disease should initially be managed with medical therapy (3). This is important because patients in COURAGE were randomized after coronary angiography was performed. High-risk patients, such as those with class IV angina, markedly positive stress test, refractory heart failure, cardiogenic shock, and an ejection fraction of less than 30% were excluded. Therefore, we recommend that the decision regarding medical therapy versus PCI should be based on the severity of symptoms and risk stratification. It is our belief that PCI is very effective in treating angina and improving functional status, and medical therapy is not superior to PCI in the management of stable coronary artery disease (3).
We agree that the use of drug-eluting stents (DES) does not reduce the likelihood of death of myocardial infarction, but DES reduce the need for target lesion revascularization. As such, there is a distinct possibility that symptom control would have been superior in the PCI arm of COURAGE had DES been used. Twenty-one percent of the PCI group required repeat revascularization during follow-up, a rate that would have likely been significantly lower had DES been used. Thus, the superiority of PCI with respect to improved relief in angina in the COURAGE may have been sustained for a longer period with DES use.
- American College of Cardiology Foundation