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Is Optimal Medical Therapy as Used in the COURAGE Trial Feasible for Widespread Use?

  • Coronary Artery Disease
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion Statement

Medical therapy is the foundation upon which all treatment for patients with stable coronary artery disease (CAD) is based, regardless of whether revascularization is performed. Although professional societies recommend comprehensive lifestyle and pharmacologic interventions with specific risk factor targets, in practice this does not usually occur. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial tested multiple simultaneous lifestyle and pharmacologic interventions (referred to as “optimal medical therapy” [OMT]) with or without percutaneous coronary intervention (PCI) in patients with stable CAD. Nurse case managers were trained to counsel patients according to protocols designed to achieve predefined lifestyle and risk factor goals. Medications were provided at no cost to patients. Adherence to lifestyle and medication prescription was very high and resulted in significant improvement in risk factor targets. COURAGE found no benefit from the addition of PCI to OMT in the primary outcome of death or myocardial infarction. OMT as delivered in COURAGE has been praised but it has also been criticized as not achievable in “real world” clinical practice. The authors, all COURAGE investigators, believe that the delivery of OMT in COURAGE represents a viable model for secondary prevention that can be translated to real practice, but acknowledge that it is difficult to do so in our fee-for-service health care system. New models of team-based healthcare to achieve evidence-based treatment targets and improved clinical outcomes are needed. Successful translation of COURAGE OMT to everyday practice will require a health care system that rewards quality of care.

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Acknowledgment

The authors would like to thank Ms. Paula Lovell (Lovell Communications, Nashville, TN) for her critical review of the manuscript.

Disclosure

David J. Maron reports no potential conflict of interest relevant to this article.

William E. Boden has received consulting fees and lecture fees from Kos Pharmaceuticals, PDL BioPharma, Pfizer, CV Therapeutics, and sanofi-aventis, and grant support from Merck & Co. and Abbott Laboratories.

William S. Weintraub has received consulting fees from sanofi-aventis and Bristol-Myers Squibb and grant support from sanofi-aventis.

Karen J. Calfas is stockholder of SanTech, Inc. a company founded in cooperation with San Diego State University and exclusively licensed to disseminate the PACE materials.

Robert A. O’Rourke has received consulting fees from King Pharmaceuticals, Lilly, and CV Therapeutics.

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Authors and Affiliations

  1. Vanderbilt Heart and Vascular Institute, 1215 21st Ave. South, MCE 5th Floor South Tower, Nashville, TN, 37232-8800, USA

    David J. Maron MD

  2. State University of New York at Buffalo and Buffalo General Hospital, Buffalo, NY, USA

    William E. Boden MD

  3. Christiana Care Health System, Newark, DE, USA

    William S. Weintraub MD

  4. University of California, San Diego, La Jolla, CA, USA

    Karen J. Calfas PhD

  5. San Antonio, TX, USA

    Robert A. O’Rourke MD

Authors
  1. David J. Maron MD
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  2. William E. Boden MD
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  3. William S. Weintraub MD
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  4. Karen J. Calfas PhD
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  5. Robert A. O’Rourke MD
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Correspondence to David J. Maron MD.

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Maron, D.J., Boden, W.E., Weintraub, W.S. et al. Is Optimal Medical Therapy as Used in the COURAGE Trial Feasible for Widespread Use?. Curr Treat Options Cardio Med 13, 16–25 (2011). https://doi.org/10.1007/s11936-010-0104-7

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  • DOI: https://doi.org/10.1007/s11936-010-0104-7

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