title: Patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention.
abstract: BACKGROUND
  The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial.
  
  
  OBJECTIVE
  To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial.
  
  
  METHODS
  An observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin).
  
  
  METHODS
  Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods.
  
  
  RESULTS
  Among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%-44.4%) before PCI and in 303,864 patients (65.0%; 95% CI, 64.9%-65.2%) at discharge following PCI (P < .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%-43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%-44.8%) after the COURAGE trial (P < .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%-63.7%) and 66.0% (95% CI, 65.8%-66.1%), respectively (P < .001).
  
  
  CONCLUSIONS
  Among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial.
authors.affiliation: Department of Medicine, Weill Cornell Medical College, Cornell University, 1305 York Ave, Eighth Floor, New York, NY 10021, USA. wbb2001@med.cornell.edu
authors.forename: William B
authors.initials: WB
authors.lastname: Borden
authors.forename: Rita F
authors.initials: RF
authors.lastname: Redberg
authors.forename: Alvin I
authors.initials: AI
authors.lastname: Mushlin
authors.forename: David
authors.initials: D
authors.lastname: Dai
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Kaltenbach
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000787:Angina Pectoris / Q000188:drug therapy* / Q000209:etiology; D015906:Angioplasty, Balloon, Coronary; D006328:Cardiac Catheterization; D002986:Clinical Trials as Topic; D003324:Coronary Artery Disease / Q000150:complications / Q000188:drug therapy*; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011788:Quality of Life; D012042:Registries; D015607:Stents; D014481:United States
chemical_list: D000319:Adrenergic beta-Antagonists; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors