Aggressive medical management of coronary artery disease versus mechanical revascularization

Abstract

The treatment of patients with stable angina has three goals: 1) minimize or eliminate ischemia (silent or symptomatic), 2) reduce morbidity, and 3) decrease mortality. Surgical and now angiographic revascularization procedures are increasingly popular approaches to the management of these patients. The results of randomized, controlled trials suggest that revascularization may not improve survival, but is useful to improve symptoms and exercise capacity. However, these trials are of limited value because they do not reflect current state of the art revascularization techniques or optimal medical management. Because many of these studies were conducted more than a decade ago, patients were recruited before the survival benefits of antiplatelet therapy, b-blockers, angiotensin-converting enzyme inhibitors, and aggressive lipid lowering were accepted. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial should help us determine the best approach in these patients. It is a multicenter, randomized trial comparing aggressive medical therapy with aggressive medical therapy with current state of the art percutaneous coronary intervention (PCI) for patients with stable coronary disease. The COURAGE protocol targets global risk reduction emphasizing 1) lifestyle modification, 2) maximal use of drugs to lower blood pressure to Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) VI goals, 3) maximal use of drugs to lower cholesterol to below National Cholesterol Education Program Adult Treatment Panel III goals for secondary prevention, and 4) maximal use of drug to alleviate anginal symptoms with or without the best interventional devices to conduct PCI.