How much courage you have in COURAGE or Extended

COURAGE?

Dr Arindam PandeConsultant Cardiologist,

Apollo Gleneagles Hospital, Kolkata

CASE HISTORY

• 54 years male • Diabetic for 4 years• Hypertensive for 6 years, on Amlodipine 5 mg• Non-smoker• No family H/O CAD• Presented with effort angina, CCS Class 2 for

last 6 months

On Evaluation..

• Resting ECG was normal • Echocardiogram revealed EF of 66% with mild

left ventricular hypertrophy • Treadmill was positive for provocable cardiac

ischemia after 7 minutes of bruce protocol

• He was advised to undergo CAG at this stage

• Coronary angiogram revealed -- 80% blockage of non-dominat LCX -- moderated disease at proximal LAD -- distal RCA stenosis

CAG

Prescription• Beta blocker, • Nitrate, • Atorvastatin, • Losartan, • Metformin, • Glipizide and • Aspirin.

--His symptoms improved with present medication

WHAT’S NEXT ??

OPTIONS..

• Continue with same medical treatment until symptoms deteriorate ?

• Gradually up titrate anti-anginal treatment?• Repeat stress test after 3 months?• Proceed with coronary intervention now, in

spite of symptom relief? • Proceed with coronary intervention in future

if symptoms deteriorate?

SPECTRUM OF SIHD

RISK ASSEESSMENT ALGORITHMIN SIHD

GDMT IN SIHD

ALGORHYTHM FOR REVASCULARIZATION IN SIHD

COURAGE

COURAGE EXTENDED

• Extended follow-up data were available for 53% of the original population at a median duration of 11.9 years, compared with a median of 6.2 years for all trial participants.

• In the original trial, 4% of patients assigned to PCI did not undergo revascularization at all and 21.1% of patients in the PCI group and 32.6% of those in the OMT group had additional revascularization.

• However, no data were available on any revascularizations that occurred during extended follow-up.

COURAGE EXTENDED…

• In the original [COURAGE] trial, the survival curves appeared to separate at 5 years in favor of PCI … which suggested that a late survival benefit with an initial management strategy of PCI may have emerged toward the end of the follow-up period

• However, after 15 years of extended follow-up, nearly half the VA patients and one quarter of the non-VA patients in the study had died, and no late trend had emerged to suggest a survival benefit with initial PCI

COURAGE EXTENDED…

• During the initial COURAGE trial, 32.6% of patients crossed over from OMT to revascularization.

• The lack of information on how many patients in the OMT group later underwent revascularization during extended follow-up is a key drawback to the current analysis

• Without this element, there can be no answer to the question of whether patients initially treated with medical therapy alone are likely to require PCI or CABG in later years.

COURAGE EXTENDED…

• Other limitations of COURAGE as a whole include little, if any, use of invasive physiologic measurements, limited use of IVUS or other newer imaging modalities, little use of DES, and a restriction in the protocol against CABG as a revascularization option.

• These limitations underscore the importance of the ongoing ISCHEMIA trial. The primary hypothesis for this newer study is that an invasive approach to stable ischemic heart disease can reduce hard clinical outcomes.

COURAGE EXTENDED…

FAME 2 TRIAL

TAKE HOME MESSAGE

• Initial therapy for SIHD should be medical management

• Medical therapy should be continued, but not at the cost of angina or quality of life

• Intervention should be performed in patients with high non-invasive risk score and refractory symptoms

• Adequate use of FFR, IVUS, DES during procedures