{"id":8214,"date":"2011-05-11T13:41:39","date_gmt":"2011-05-11T17:41:39","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=8214"},"modified":"2011-07-19T17:45:09","modified_gmt":"2011-07-19T21:45:09","slug":"optimal-medical-therapy-and-the-lack-of-courage","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/05\/11\/optimal-medical-therapy-and-the-lack-of-courage\/","title":{"rendered":"Optimal Medical Therapy and the Lack of COURAGE"},"content":{"rendered":"<p><em>We welcome William Borden and John Spertus to answer questions from CardioExchange Editor-in-Chief Harlan Krumholz about their <\/em>JAMA <em>paper showing that optimal medical therapy (OMT) for patients with coronary artery  disease (CAD) did not receive a meaningful boost from the publication of the <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa072771\">COURAGE<\/a> trial, despite the trial&#8217;s clear message showing the benefits  of OMT.<\/em><\/p>\n<p><em> Using data on 467,211 patients in the  National Cardiovascular Data Registry to analyze the use of OMT in CAD  patients prior to PCI and at the time of discharge, both before and  after COURAGE was published, they found:<br \/>\n<\/em><\/p>\n<ul>\n<li><em> Before PCI: OMT was used in 43.5% of patients before COURAGE\u00a0 and 44.7%  after COURAGE.<\/em><\/li>\n<li><em> At discharge after PCI: OMT was used in 63.5% of patients before and  66.0% after COURAGE.<\/em><\/li>\n<\/ul>\n<p><em>&#8220;Collectively, these findings suggest a significant opportunity for  improvement and a limited effect of an expensive, highly publicized  clinical trial on routine clinical practice,&#8221; the authors wrote.<\/em><\/p>\n<p><strong><em>Krumholz: <\/em>Could the low rate of OMT be a result of patient preference?<\/strong><\/p>\n<p><em><strong>Borden and Spertus: <\/strong><\/em>In our study, the low rate of OMT is not due to patient preference, since our database documents only those medications prescribed by the physician, not whether or not the patients were actually taking the medicines.\u00a0 Also, if a physician did not prescribe a medication because of patient preference, then that preference could be documented as a contraindication, which would not lower the OMT rate.<\/p>\n<p><strong><em>Krumholz: <\/em><\/strong><strong>Are you sure about the quality of the medication data in the CathPCI registry?<\/strong><\/p>\n<p><em><strong>Borden and Spertus: <\/strong><\/em>The medication data in the CathPCI registry are reported by the individual institutions according to rigorous data definitions and training. \u00a0We cannot confidently exclude the possibility that these are not accurately abstracted, although registering patients&#8217; medications on admission is a standard of care and should render these data easy to identify and record. \u00a0Moreover, there is no reason to think that the quality of the medication data would have changed from the pre-COURAGE to the post-COURAGE period, and finding no meaningful increase in the use of OMT after COURAGE suggests that among the patients undergoing PCI, clinicians are not being substantially more aggressive in attempting OMT to see whether PCI could be avoided.<\/p>\n<p><strong><em>Krumholz: <\/em><\/strong><strong>What do you recommend for someone with a high-risk study who does not want to try medications?<\/strong><\/p>\n<p><em><strong>Borden and Spertus: <\/strong><\/em>Ultimately we believe that patients are autonomous and can request procedures that are medically reasonable. Based on the 2009 ACC\/AHA Appropriateness Criteria for Coronary Revascularization, someone with a high-risk stress test on no medications would be considered appropriate for revascularization. However, we would want to be sure that the patient clearly understood that the procedure is not likely to make him or her live longer or prevent a heart attack. \u00a0Furthermore, the patient would still be encouraged to take aspirin, thienopyridines, statins, and beta-blockers. The PCI does not obviate the benefit of these medications. The primary benefit of revascularization would be the alleviation of symptoms, which might also be accomplished with aggressive OMT alone.<\/p>\n<p><strong><em>Krumholz: <\/em><\/strong><strong>Why do you think this is inadequate translation of COURAGE? Couldn&#8217;t this be a conscious decision by patients and their doctors after taking\u00a0into account COURAGE?<\/strong><\/p>\n<p><em><strong>Borden and Spertus: <\/strong><\/em>Our study does not preclude the possibility that some practitioners are following the COURAGE insights with attempting OMT in their stable angina patients and not referring them to PCI, as we only studied those patients who underwent PCI. \u00a0In fact, <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21505155\">a recent publication by Ahmed and colleagues<\/a> noted a decrease in the proportion of PCI patients with stable angina in Northern New England. \u00a0However, among those referred to PCI, we did not appreciate substantial increases in the use of OMT prior to treatment. While I doubt that this is a conscious decision of patients, there are a number of potential explanations, including possible clinicians&#8217; disbelief of the COURAGE results, economic incentives to preferentially treat with revascularization, referral patterns, and concerns of interventionalists that if they don\u2019t perform the PCI for a referring doctor that the doctor will not refer future patients.\u00a0 More work is clearly needed to illuminate the opportunities to further improve the use of OMT prior to, and after, PCI.<\/p>\n<p><strong><em>Krumholz: <\/em><\/strong><strong>How would you improve current care?<\/strong><\/p>\n<p><em><strong>Borden and Spertus: <\/strong><\/em>One key step to improving care may be through better collaboration among caregivers.\u00a0 Primary and interventional cardiologists could work together to ensure that patients, both before and after PCI, are on appropriate medical therapies.\u00a0 Supporting such collaboration and emphasizing medical management should be a priority of ongoing efforts toward improving our healthcare system.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>We welcome William Borden and John Spertus to answer questions from CardioExchange Editor-in-Chief Harlan Krumholz about their JAMA paper showing that optimal medical therapy (OMT) for patients with coronary artery disease (CAD) did not receive a meaningful boost from the publication of the COURAGE trial, despite the trial&#8217;s clear message showing the benefits of OMT. [&hellip;]<\/p>\n","protected":false},"author":490,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[371,838,301],"class_list":["post-8214","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology","tag-courage","tag-optimal-medical-therapy","tag-pci"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/8214","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/490"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=8214"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/8214\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=8214"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=8214"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=8214"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}