COURAGE sent shock waves through the cardiology community. There were immediately efforts to refine or discredit it. Some commentators said it was old news, citing previous smaller studies that showed the same thing. Others pointed to subgroups of patients (women, people with severely limited coronary blood flow) that seemed to do better with the more aggressive treatment.
But the message has remained clear: Cardiologists are jumping to angioplasty and stenting too quickly in lots of patients.
“The use of PCI in certain settings can be lifesaving; however, PCI is clearly being performed more often than appropriate,” cardiologist Rita F. Redberg of the University of California at San Francisco wrote last fall in the Archives of Internal Medicine.
A small shift
In the half-decade since the study came out, things have changed a little. But not much.
The annual number of PCI procedures in the United States has gone down slightly. How much of that is a change of practice and how much a consequence of the steady 50-year decline in heart disease isn’t clear.
It may be that fewer people are getting PCI for stable angina now. That was the case in a registry of 26,000 patients in northern New England, where that diagnosis was given in 21 percent of procedures in the year before COURAGE was published but in only 16 percent in the years just after it. Whether that reflects a national trend also isn’t known.
On the other hand, physicians’ willingness to give “optimal medical therapy” a real try before taking a patient to the procedure room hasn’t budged. A study published last year showed that before COURAGE, 44 percent of patients with stable angina getting PCI had fully attempted drug-and-lifestyle treatment before turning to the procedure. After COURAGE, that went up one click, to 45 percent.
Why hasn’t there been more change?
“It’s easier to get people to start something new than to give up something they’ve been doing for a long time,” said Mark A. Hlatky, a cardiologist at Stanford University. Change also comes more readily if something causes actual harm rather than just doesn’t do any good.
(That was the case when studies in the 1950s showed that routinely giving extra oxygen to premature babies was causing thousands of them to go blind. Pediatricians wised up quickly.)
As a rule, “nothing changes that fast in medicine,” said Hlatky, who writes widely on health policy. “It’s not enough to just prove that something works. There’s a whole secondary task of getting it into practice.”
The problem, though, may be deeper than that. It may lie in the culture of American medicine, which with little exagerration can be summed up by the sentence: “Don’t just stand there, do something!”