Title: Intensive Multifactorial Intervention for Stable Coronary Artery Disease: Optimal Medical Therapy in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) Trial
Topic: Prevention/Vascular
Date Posted: 3/22/2010 5:00:00 PM
Author(s): Maron DJ, Boden WE, O’Rourke RA, et al.
Citation: J Am Coll Cardiol 2010;55:1348-1358.
Clinical Trial: No
Related Resources
JACC Article: Intensive Multifactorial Intervention for Stable Coronary Artery Disease: Optimal Medical Therapy in the COURAGE Trial
Trial: Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE)
Study Question: What is the effect of the medical therapy used in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial on coronary risk factors?
Methods: The COURAGE trial tested multiple lifestyle and pharmacologic interventions (optimal medical therapy) with or without percutaneous coronary intervention (PCI) in patients with stable coronary disease. All patients, regardless of treatment assignment, received equivalent lifestyle and pharmacologic interventions for secondary prevention. Most medications were provided at no cost. Therapy was administered by nurse case managers according to protocols designed to achieve predefined lifestyle and risk factor goals. The primary outcome of this analysis is change in coronary risk factors.
Results: A total of 2,287 patients were followed for an average of 4.6 years. There were no differences between groups (PCI or no-PCI at baseline) for the following: mean age was 62 years, 85% male, 86% white, 32% diabetic, 66% hypertensive, 23% current smokers, and 38% had a previous myocardial infarction. Mean baseline values were: low-density lipoprotein cholesterol (LDL-C) 101 mg/dl, high-density lipoprotein cholesterol 39 mg/dl, triglycerides 145 mg/dl, and body mass index 28.8 kg/m2. There were no significant differences between treatment groups in proportion of patients achieving therapeutic goals. The proportion of smokers decreased from 23% to 19% (p = 0.025), those who reported <7% of calories from saturated fat increased from 46% to 80% (p < 0.001), and those who walked ≥150 minutes/week increased from 58% to 66% (p < 0.001). Body mass index increased from 28.8 ± 0.13 kg/m2 to 29.3 ± 0.23 kg/m2 (p < 0.001). Appropriate medication use increased from prerandomization to 5 years as follows: antiplatelets 87% to 96%; beta-blockers 69% to 85%; rennin-angiotensin-aldosterone system inhibitors 46% to 72%; and statins 64% to 93%. Systolic blood pressure decreased from a median of 131 ± 0.49 mm Hg to 123 ± 0.88 mm Hg. LDL-C decreased from a median of 101 ± 0.83 mg/dl to 72 ± 0.88 mg/dl.
Conclusions: Secondary prevention was applied equally and intensively to both treatment groups in the COURAGE trial by nurse case managers with treatment protocols, and resulted in significant improvement in risk factors. Optimal medical therapy in the COURAGE trial provides an effective model for secondary prevention among patients with chronic coronary disease.
Perspective: Congratulations to the COURAGE nurse clinical case managers and investigators. The risk factor reduction in COURAGE far exceeds community practice. One of the messages from this analysis is that nurse case managers trained in changing behavior, nutrition, exercise, smoking cessation, and evidence-based drug therapies provide a standard of care that can exceed that of busy practitioners. Institutions and physicians should consider incorporating nurse case manager care for patients with coronary disease, possibly in consort with cardiac rehabilitation that includes several follow-up visits over the first year. Melvyn Rubenfire, M.D., F.A.C.C.
Title: Alcohol Consumption and Cardiovascular Mortality Among U.S. Adults, 1987 to 2002
Topic: Prevention/Vascular
Date Posted: 3/22/2010 5:00:00 PM
Author(s): Mukamal KJ, Chen CM, Rao SR, Breslow RA.
Citation: J Am Coll Cardiol 2010;55:1328-1335.
Clinical Trial: No
Related Resources
JACC Article: Alcohol Consumption and Cardiovascular Mortality Among U.S. Adults, 1987 to 2002
Study Question: Is alcohol consumption associated with cardiovascular (CV) mortality?
Methods: Data from the National Health Interview Survey, an annual survey of US adults, were used for the analysis. Surveys from 1987 to 2002 were included. Alcohol consumption was examined by usual volume, frequency, and quantity. Information on binge drinking was also included. The outcome of interest was CV mortality, which was obtained through linkage to the National Death Index through 2002.
Results: A total of 245,207 US adults were included in this study, and 10,670 CV disease (CVD) deaths occurred over 1,987,439 person-years of follow-up. Light and moderate alcohol consumption was inversely associated with CV mortality. Compared to lifetime abstainers, a trend towards decreased CVD mortality was observed among lifetime infrequent drinkers (relative risk [RR], 0.95; 95% confidence interval [CI], 0.88-1.02), former drinkers (RR, 1.02; 95% CI, 0.94-1.11), and heavy drinkers (RR, 0.95; 95% CI, 0.82-1.10), whereas a significant decreased risk was observed for light drinkers (RR, 0.69; 95% CI, 0.59-0.82) and moderate drinkers (RR, 0.62; 95% CI, 0.50-0.77). These risks were similar in subgroups of age, sex, and baseline health status. No significant association was observed for CVD mortality and binge drinking. In looking at number of drinks per day, those who consumed three or more drinks per day had an increased risk of CVD mortality compared to those who consumed two drinks per day.
Conclusions: The authors concluded that light and moderate alcohol consumption was associated with reduced CVD mortality among a nationally representative sample of US adults, as compared with lifetime abstainers.
Perspective: These data support current recommendations that light (defined as current use of ≤3 drinks per week) to moderate (defined as >3 to 7 drinks per week for women and >3 to 14 drinks per week for men) alcohol consumption is not associated with increased CVD mortality. However, as the authors point out, this study is observational, and thus, confounding may influence these findings. Clinicians should continue to assess alcohol patterns among their patients, with recommendations tailored to the individual patient’s comorbidities, medication use, and preferences. Elizabeth A. Jackson, M.D., F.A.C.C.