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Heart 99:442-444 doi:10.1136/heartjnl-2012-303029
  • Editorial

COURAGE or FAME…? Who should have percutaneous coronary intervention in stable coronary artery disease?

  1. Keith A A Fox
  1. Correspondence to Professor Keith A A Fox, Department of Cardiology, Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK; k.a.a.fox{at}ed.ac.uk

A patient has just been diagnosed with stable coronary artery disease (CAD) and turns to the doctor and asks ‘Do I need a stent for this doctor?’ The answer, based on current evidence, is not simple.

First, there is poor appreciation among clinicians and among patients about the relatively benign prognosis in stable CAD. For example, in the 3825 patients with stable symptomatic CAD in the A Coronary Disease Trial Investigating Outcome with Nifedipine (ACTION) trial there were 1.5 deaths per 100 patient-years at risk and 1.4 myocardial infarctions (MI).1 Furthermore, the use of statins (62%), ACE inhibitors or angiotensin II receptor blockers (ARB) and other secondary prevention measures did not achieve the levels attained in the subsequent COURAGE trial (95% on statins at 1 year, 95% on aspirin, 89% on beta blockers, 72% on ACE or ARB).2 However, the overall figure masks a 10-fold range in risk, determined by concomitant risk factors including the extent of coronary disease3 (figure 1). So, the first response to the patient is reassuring; unless there are additional risk factors, the risks of death are relatively low and are reduced by secondary prevention treatments and lifestyle measures including smoking cessation.

Figure 1

Impact of underlying risk on probability of death or myocardial infarction (MI) or stroke within 5 years in patients with stable ischaemic heart disease. (Principally: age, ejection fraction, diabetes, smoking, previous MI, renal dysfunction, extent of coronary disease, hypertension, no lipid-lowering therapy).3

The next question from the patient is ‘Okay, I will take the treatments you prescribe for preventing complications and do my best to adopt the lifestyle changes, but would I be better off with stent therapy?’ If the patient is symptomatic and is not controlled or is inadequately controlled on anti-anginal medications (because of troublesome angina or side effects) then …