The COURAGE Trial Aftermath – No Change in Practice

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Merrill Goozner

First published 5/11/11 on Gooz News

The COURAGE trial, announced with great fanfare in 2007, showed giving drugs and counseling to people with stable coronary artery disease was just as effective in reducing heart attacks, strokes and early death as subjecting patients to balloon angioplasty and inserting stents, which are far more expensive procedures than giving drugs. And how did the nation’s cardiologists respond to this startling news, which, if you were a cardiologist, you had to be living in Abbottabad to miss? A study in today’s Journal of the American Medical Association showed (from MedPage Today):

Publication of the results of the COURAGE trial appears to have had little effect on real-world use of optimal medical therapy before percutaneous coronary intervention (PCI) and at discharge in patients with stable coronary artery disease, researchers found. . . (Among) more than 460,000 patients, the percentage who received optimal medical therapy with an antiplatelet agent, a beta-blocker, and a statin before PCI actually increased slightly — from 43.5% to 44.7% — after COURAGE was reported. . . The proportion who received optimal medical therapy at discharge after PCI also rose slightly, from 63.5% to 66%. Although the changes were statistically significant, both had marginal clinical significance, the authors noted. “Collectively, these findings suggest a . . . limited effect of an expensive, highly publicized clinical trial on routine clinical practice,” they wrote.

This depressing survey confirms that for many physicians, medicine remains an evidence-free zone. The authors call for “innovations in . . . improving the translation of clinical evidence into practice.” I’ve got an idea. How about not paying for percutaneous coronary interventions in stable coronary artery disease where drugs and counseling weren’t tried first? That would be truly innovative. (Shhh. I have to sneak out of here to go to my day job before the rationing police come to get me.)

Merrill Goozner is an independent health journalist who maintains a blog at Gooz News.

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