Cardiology

Indian Cardiologists Find Flaws in Courage Trial

The study suggests that patients with partially obstructed arteries can put off angioplasty or skip surgery altogether

The recent 'Clinical Outcomes Utilising Revascularisation and Aggressive Drug Evaluation' (Courage) Study funded primarily by the US Department of Veterans' Affairs and presented at the American College of Cardiology's annual meeting in New Orleans found that angioplasty works no better than medication at preventing heart attacks or death. The trial has created uproar within the cardiologists' fraternity world over with the discussions of the actual worth of stents and interventions being analysed afresh along with the credibility of the trial itself.

The study, published in The New England Journal of Medicine, suggest that patients with partially obstructed arteries can put off angioplasty or skip surgery altogether. Half of the 2,300 patients studied underwent angioplasty and took heart drugs, and were told to make lifestyle changes, such as exercising, losing weight, and giving up smoking. The other half received only lifestyle counseling and medication, including drugs to lower cholesterol, relax blood vessels, slow heart rate, and prevent blood clots. Both groups fared equally well after an average of four-and-a-half years, according to the study. "In this study, it is emphatically shown that if the patient is of chronic stable angina, either of the therapies is good with the same long-term results. And if the patients are not optimsed with the medical therapy, only then should they be treated with angioplasty/interventions," opines Dr Pankaj Bohra, Consultant Interventional Cardiologist, Soni Hospital, Jaipur.

For some prominent Indian cardiologists, the trial is flawed as it takes into consideration only the chronic stable angina patients. "This trial has not come up with any new data. Moreover, it is already a known fact that in this specific subset of patients, the medical therapy is as good or may be slightly superior to intervention," says Dr Brian Pinto, Director, Cathlab and Head of Cardiology, Holy Family Hospital, Mumbai. Also, one can witness patients with chronic stable angina who cannot be controlled by medical therapy are crossed over to interventions.

"Moreover, in the Indian practice, it is found that among the total number of interventions performed, this group of patients with chronic stable angina contribute only up to 10 per cent, whereas 60 to 70 per cent patients are found with unstable angina and remaining with acute MI," explains Dr Anand Rao, Interventional Cardiologist, Holy Family Hospital.

In the Indian scenario, as most of the patients coming for interventions are with unstable angina or acute MI, they certainly need the intervention. This trial will therefore unnecessarily frighten them, opines Dr Pinto.

While talking about the authenticity of this particular trial, Dr Aftab Khan, Interventional Cardiologist, Apollo Gleneagles Hospital, Kolkata, says, "Overall, 35,000 patients were screened out of which only 2,300 patients were selected. The question is, why did they select only a minuscule patients after screening so many of them. The trial excluded patients with unstable angina, and patients with poor heart pumping." According to Dr Yusuf Kumble, Chief Interventional Cardiologist, Manipal Hospital, Mangalore, The study is like putting the old wine in a new bottle, where not much has been analysed about the present practices.

Sonal Shukla