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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;8\\\/6\\\/30\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;8\\\/6\\\/30\u0022}],\u0022ac\u0022:{\u0022spmdc;8\\\/6\\\/30\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;8\\\/6\\\/30\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE] trial evaluated percutaneous coronary intervention (PCI) as an initial management strategy in patients with stable coronary artery disease. Patients were randomly assigned to treatment with PCI in addition to medical therapy (n=1149) or medical therapy alone (n=1138). In the primary analysis, PCI did not reduce the risk of death or nonfatal myocardial infarction [Boden WE et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices clinical trials\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EThe COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial evaluated percutaneous coronary intervention (PCI) as an initial management strategy in patients with stable coronary artery disease (CAD). Patients were randomly assigned to treatment with PCI in addition to medical therapy (n=1149) or medical therapy alone (n=1138). In the primary analysis, PCI did not reduce the risk of death or nonfatal myocardial infarction (MI) [Boden WE et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007]. In this session, presenters discussed lessons from the COURAGE (\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00007657\u0026amp;atom=%2Fspmdc%2F8%2F6%2F30.atom\u0022\u003ENCT00007657\u003C\/a\u003E) trial.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOptimal Medical Therapy For Most Patients\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EWilliam E. Boden, MD, University of Buffalo, Buffalo, NY, argued in support of medical therapy as the initial choice in chronic stable angina. In 2007, Ford and colleagues described trends in cardiovascular mortality between 1980 and 2000 in the US [Ford ES et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007]. During this time period, the age-adjusted death rate for coronary heart disease (CHD) decreased by approximately half. As a result of the decreased mortality rate, there were 341,745 fewer deaths from CHD in 2000 versus 1980. The decreasing mortality that was observed in the US mirrors trends that have been observed worldwide (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022International Trends in CHD Mortality, 1968\u0026#x2013;2003.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-478643240\u0022 data-figure-caption=\u0022International Trends in CHD Mortality, 1968\u0026#x2013;2003.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/6\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11128\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EInternational Trends in CHD Mortality, 1968\u20132003.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EIn the US study, researchers evaluated the causes of improved survival. They attributed 47% of the decline in mortality to the use of evidence-based medical therapies, including statins, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and other drug classes. An additional 44% of the decrease was due to positive changes in risk factors, such as decreased cholesterol levels, lower blood pressure, less smoking, and an increase in physical activity.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EOnly 5% of the increase in CHD-related survival was attributed to revascularization procedures for chronic stable angina. Specifically, PCI was responsible for only 1.3% of the improved survival that was observed between 1980 and 2000. \u201cAlthough routine PCI provides some advantages in angina, they are numerically small, are not durable, and are achieved only at an unattractive cost for chronic disease management,\u201d Dr. Boden said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn summary, Dr. Boden said that aggressive medical therapy without initial PCI can be implemented safely in patients with stable CAD. Starting treatment with optimal medical therapy incurs no disadvantage with respect to death, MI, acute coronary syndrome, or revascularization, he concluded.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIdentifying Patients For Revascularization\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EMarc E. Shelton, MD, Prairie Heart Institute, Springfield, IL, discussed strategies for identifying patients who are most likely to benefit from PCI. Among patients with chronic stable angina, the goals of PCI are to decrease symptoms, relieve ischemia, and reduce the need for subsequent procedures. However, PCI does not reduce the risk of death or MI in aggregate groups of patients with chronic stable angina and should not be used with these goals primarily in mind, Dr. Shelton said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EWhen considering the potential utility of PCI in specific patients, it is important to consider the extent of ischemia. In 2003, Hachamovitch and colleagues showed that revascularization has a greater survival benefit compared with medical therapy in patients with moderate to large amounts of inducible ischemia [Hachamovitch R et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003]. The survival benefit of revascularization over medical therapy was seen in patients in whom more than 10% of the myocardium was at risk.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EDr. Shelton also emphasized the importance of medication adherence, whether patients are treated with optimal medical therapy or revascularization. Currently, only 40% of patients with CAD adhere to statin therapy after 2 years, and 1 in 7 patients who receive a drug-eluting stent does not continue antiplatelet therapy for 30 days following the procedure [Jackevicius CA et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008; Spertus JA, et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn conclusion, in patients with chronic stable angina, Dr. Shelton suggested that PCI should be reserved for patients who have failed optimal medical therapy. In particular, patients who have significant myocardial risk areas and who are likely to be compliant with dual antiplatelet therapy are ideal candidates, he said.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/6\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmdh2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmdh2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}