PCI provides short-term quality of life improvement in stable angina (COURAGE)
Does percutaneous coronary intervention improve the quality of life for patients with stable coronary artery disease?
For patients with stable angina, percutaneous coronary intervention (PCI) offers modest symptomatic and quality of life benefit for the first year after the procedure (number needed to treat [NNT] = 9 - 11). The benefit diminishes over time and disappears after 3 years. (LOE = 1b)
Weintraub WS, Spertus JA, Kolm P, et al, for the COURAGE Trial Research Group. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med 2008; 359(7):677-687. [PMID:18703470]
Randomized controlled trial (nonblinded)
Patients (N = 2287) with stable angina were randomly assigned to receive intensive medical therapy or PCI followed by intensive medical therapy. All had at least one proximal vessel with 70% stenosis and evidence of myocardial ischemia or at least one proximal vessel with 80% stenosis accompanied by classic angina without provocative testing. Intensive medical therapy consisted of aspirin or clopidogrel, metoprolol, amlodipine, and/or isosorbide mononitrate, and lisinopril or losartan. Simvastatin with or without ezetimibe (Zetia) was used to achieve a low-density lipoprotein level of less than 85 mg/dL (2.2 mmol/L). Exercise, extended-release niacin, and/or fibrates were used to achieve a high-density lipoprotein level of greater than 40 mg/dL (1.03 mmol/L) and a triglyceride level of less than 150 mg/dL (1.67 mmol/L). Most patients did not receive a drug-eluting stent. The researchers had previously published the clinical outcomes for the study, finding that there was no difference between groups with regard to mortality and cardiovascular events over 4.6 years. (N Engl J Med 2007;356:1503-16; POEM #90603) In this study, the authors measured quality of life with the RAND 36-item health survey (RAND-36) and the disease-specific Seattle Angina Questionnaire. Groups were balanced at baseline, with 21% in the PCI group and 23% in the medical therapy-only group free of angina. Quality of life and freedom from angina were measured at 1, 3, 6, 12, 24, and 36 months. There was a consistent benefit of PCI plus medical therapy at 1 month, 3 months, and 6 months (absolute risk reduction [ARR] = 9% - 11%; NNT = 9 - 11). This diminished somewhat at 12 months (ARR = 7%; NNT = 14) and 24 months (ARR = 6%; NNT = 17). By 36 months, there was no significant difference in freedom from angina between groups (59% vs 56%). A similar pattern of diminishing benefit was seen for subscale and overall scores on both the Seattle Angina Questionnaire and the RAND-36 health survey.
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