A new quality-of-life (QOL) analysis from the COURAGE trial has just been published in the New England Journal of Medicine. This latest analysis shows that QOL was substantially improved whether patients received stenting or medical therapy. While gains in QOL were somewhat higher with stenting than with medical treatment, that difference lasted for only a year or two. By year three, QOL was the same in both groups.
Critics of the COURAGE trial point out that drug-eluting stents (DES) were not used in this trial, and that in the real world many patients treated medically for angina are not treated optimally. However, DES create their own special dilemma (which critics of COURAGE seem reluctant to mention), and it somehow seems self-serving for cardiologists to default to stenting because doctors (quite often the cardiologists themselves) fail to give optimal medical therapy.
The bottom line: The QOL analysis of the COURAGE trial supports the initial conclusions of the study as reported in 2007. Stenting does not offer any improvement in mortality or heart attack prevention over optimal medical therapy, and any differences in QOL between the two forms of therapy are transient.
So: In patients with stable angina, it is quite reasonable to try optimal medical therapy as the first step. If optimal medical therapy fails to adequately control symptoms, then stenting can be done as a second step.
Sources:
Weintraub WS, Spertus JA, Kolm P, et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med 2008; 359:677-687.
Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356:1503-16.