Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden - Results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy

被引:1234
作者
Shaw, Leslee J. [1 ]
Berman, Daniel S. [2 ]
Maron, David J. [3 ]
Mancini, John
Hayes, Sean W. [2 ]
Hartigan, Pamela M. [4 ]
Weintraub, William S. [5 ]
O'Rourke, Robert A. [6 ]
Dada, Marcin [7 ]
Spertus, John A. [8 ]
Chaitman, Bernard R. [9 ]
Friedman, John [2 ]
Slomka, Piotr [2 ]
Heller, Gary V. [6 ]
Germano, Guido [2 ]
Gosselin, Gilbert [10 ]
Berger, Peter [11 ]
Kostuk, William J. [12 ]
Schwartz, Ronald G. [13 ]
Knudtson, Merill [14 ]
Veledar, Emir [1 ]
Bates, Eric R. [15 ]
McCallister, Benjamin [8 ]
Teo, Koon K. [16 ]
Boden, William E. [17 ]
机构
[1] Emory Univ, Sch Med, Atlanta, GA 30322 USA
[2] Cedars Sinai Med Ctr, Los Angeles, CA 90048 USA
[3] Vanderbilt Univ, Med Ctr, Nashville, TN USA
[4] Vet Affairs Connecticut Healthcare Syst, Vet Affairs Cooperat Studies Program Coordinating, West Haven, CT USA
[5] Christiana Care Hlth Syst, Newark, DE USA
[6] S Texas Vet Hlth Care Syst, San Antonio, TX USA
[7] Hartford Hosp, Hartford, CT 06115 USA
[8] Univ Missouri, Mid Amer Heart Inst, Kansas City, MO 64110 USA
[9] St Louis Univ, St Louis, MO 63103 USA
[10] Montreal Heart Inst, Montreal, PQ H1T 1C8, Canada
[11] Weis Ctr Res, Geisinger Clin, Danville, PA 17822 USA
[12] London Hlth Sci Ctr, London, ON, Canada
[13] Univ Rochester, Rochester, NY USA
[14] Foothills Prov Gen Hosp, Calgary, AB T2N 2T9, Canada
[15] Univ Michigan, Ann Arbor, MI 48109 USA
[16] McMaster Univ, Hamilton, ON, Canada
[17] SUNY Buffalo, Western New York Vet Affairs Healthcare Network, Buffalo Gen Hosp, Buffalo, NY 14260 USA
关键词
ischemia; perfusion; prevention; prognosis;
D O I
10.1161/CIRCULATIONAHA.107.743963
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background-Extent and severity of myocardial ischemia are determinants of risk for patients with coronary artery disease, and ischemia reduction is an important therapeutic goal. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) nuclear substudy compared the effectiveness of percutaneous coronary intervention (PCI) for ischemia reduction added to optimal medical therapy (OMT) with the use of myocardial perfusion single photon emission computed tomography (MPS). Methods and Results-Of the 2287 COURAGE patients, 314 were enrolled in this substudy of serial rest/stress MPS performed before treatment and 6 to 18 months (mean = 374 +/- 50 days) after randomization using paired exercise (n = 84) or vasodilator stress (n = 230). A blinded core laboratory analyzed quantitative MPS measures of percent ischemic myocardium. Moderate to severe ischemia encumbered >= 10% myocardium. The primary end point was >= 5% reduction in ischemic myocardium at follow-up. Treatment groups had similar baseline characteristics. At follow-up, the reduction in ischemic myocardium was greater with PCI+OMT (-2.7%; 95% confidence interval, -1.7%, -3.8%) than with OMT (-0.5%; 95% confidence interval, -1.6%, 0.6%; P < 0.0001). More PCI+OMT patients exhibited significant ischemia reduction (33% versus 19%; P=0.0004), especially patients with moderate to severe pretreatment ischemia (78% versus 52%; P = 0.007). Patients with ischemia reduction had lower unadjusted risk for death or myocardial infarction (P = 0.037 [risk-adjusted P = 0.26]), particularly if baseline ischemia was moderate to severe (P = 0.001 [risk-adjusted P=0.08]). Death or myocardial infarction rates ranged from 0% to 39% for patients with no residual ischemia to >= 10% residual ischemia on follow- up MPS (P=0.002 [risk-adjusted P=0.09]). Conclusions-In COURAGE patients who underwent serial MPS, adding PCI to OMT resulted in greater reduction in ischemia compared with OMT alone. Our findings suggest a treatment target of >= 5% ischemia reduction with OMT with or without coronary revascularization.
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收藏
页码:1283 / 1291
页数:9
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