DR. HOOK- Take courage: Medical therapy as good as surgery

Courage: what does it mean to you? To the cowardly lion in The Wizard of Oz, it meant he would be king of the forest (though personally I think Queen would be more fitting). For Kerri Strug, the Olympic gymnast, it meant landing on one leg on the vault event to ensure a gold medal for Team USA! (Poor thing, she never became a huge American sensation because her voice lacks– courage. Plus her head bobbed up and down while reading the teleprompter at the Grammys.) 

For Newt Gingrich, courage was telling the world he was cheating on his wife at the same time he was impeaching President Clinton– or wait, is that just stupidity and hypocrisy?

In the New England Journal of Medicine (March 27, 2007), COURAGE means "Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation." Where do they get these acronyms? A TV reality show should give away $1 million for someone to design a study using the acronym "THISSTUDYKEEPSMETENUREDATTHEUUNIVERSITY." 

So, what is Courage?

PCI is coronary artery intervention done during cardiac catheterization (aka cath). A clogged artery can be balloon-opened, and even a stent can be positioned to keep the lumen of the artery from closing up again. Over a million PCIs are done on Americans every year, and 85 percent of them are elective. PCI done during an acute coronary event (like a heart attack) has been shown to save lives. But it hasn't been shown to save lives or prevent non-fatal heart attacks in people with stable coronary artery disease vs. medical management alone.

Now before you decide, "Hey, I'm not getting a cath or PCI for my angina," realize this recent study is pretty narrow– including only those with stable coronary artery disease– and this study kicked out about 33,000 people who didn't meet the criteria– sorta like American Idol auditions. Almost all the patients were white men in their 60s.

Between 1999 and 2004, Canadian and American veterans hospitals recruited 2,287 patients with stable coronary disease and randomized them into two groups: PCI and medical therapy only. The PCI group had intervention done and were then treated with diet and exercise counseling and medications exactly like the medical therapy group. You would think the PCI group would fare better since their partially closed-up coronaries were opened and they got good medical treatment afterward. But as with Miss USA, Tara Conner, the outcomes were dismal.

Death from any cause and non-fatal heart attacks were basically the same between the two groups: 19 percent for PCI group, 18.5 percent for medical therapy only group (no statistical difference) after a median of 4.6 years of follow-up. The study's secondary outcome of death, heart attack, and stroke was also the same for both groups.

So why didn't the PCI group have better outcomes than the medical therapy only group? It could be the morphology of the atherosclerotic plaques in the coronary arteries. Atherosclerotic plaques can burst and attract platelets to form a clot in the artery– leading to a heart attack. But in stable coronary disease, the plaques might be more stable and less likely to form a clot– so perhaps they don't need PCI.

Nonetheless, with 19 percent of people dying or having a heart attack in 4.6 years with aggressive medical therapy, heart disease remains the #1 killer of Americans. And no surprise: there wasn't any weight loss in both groups despite well-controlled cholesterol, blood pressure, and sugars.

I think it takes courage to read peer-reviewed journal medical articles. They're long, boring, often depressing, and filled with numbers to make my epidemiological mind go bonkers. I en-courage you to reduce your cardiac risks.