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The COURAGE trial results show that patients with stable coronary artery disease who have a good quality of life while receiving medical treatment do not require an angioplasty.1 Coronary angioplasty in the United Kingdom is generally used to treat stable patients who have angina while receiving medical treatment. This trial therefore has little relevance to UK practice.
Of patients randomised, 43% had little or no angina. In addition one third of patients in the “optimal medical treatment” arm had an angioplasty by 4.6 years, presumably because of angina while receiving optimal medical treatment. It would be interesting to know how many of these patients started the trial with important (class II or III) angina. The trial may actually show that most patients with class II or III angina will require an angioplasty within five years because optimal medical treatment will not control their symptoms. The primary end point of death or non-fatal myocardial infarction is peculiar and was designed to see angioplasty fail. Interventional cardiologists have never argued that angioplasty affects mortality or reduces the incidence of myocardial infarction. The only patients in whom angioplasty may have a chance of producing this effect, those with left main or severely reduced left ventricular function, were excluded from the trial. This implies that if the trial was repeated, but with surgery as the method of revascularisation, no mortality benefit would have resulted because the only patients for which there is a real mortality benefit from revascularisation have been excluded from the trial.
Most coronary angioplasty in the UK is used to treat patients with unstable syndromes, including acute myocardial infarction, rather than patients with stable angina. Interventional cardiologists in the UK will continue to use optimal medical treatment as we have always done, and angioplasty will remain the dominant mode of revascularisation for the foreseeable future.
Competing interests: None declared.