Our Optimal Medical Therapy                                                                   

Those who criticized the validity of the results of the COURAGE Trial claimed that the Optimal Medical Therapy in the COURAGE Trial is not achievable in real-world practice and therefore the conclusions can’t be applied outside the settings of the clinical trial. That is a false statement. Our published data in 2006 and in 2016 demonstrated of our Optimal Medical Therapy was comparable (2006) and even surpassed (2016) the COURAGE Trial. The 2013 ACC/AHA guidelines, in contradiction to the NCEP ATP III guidelines, by promoting fixed statin dosing, represented a major effort to set us back to the pre-COURAGE Trial era.

Optimal medical therapy includes LDL-c/LDL-p cholesterol lowering therapy, diabetes control (HgbA1c less than 6.5), blood pressure control (systolic BP less than 130), smoking cessation, regular exercise, weight control and stress management.

Optimal medical therapy prescribed by clinicians are not all the same. It depends on their experience, their training, whether they have a clinical management system or not (like daily self chart audit, etc.) or the financial impact of large reductions in heart attack and stroke patients to them or their employer’s finances. Atherosclerosis is the goose that lays the golden egg. Heart attack and stroke have fueled and sustained the growth of a large cardiovascular healthcare industry for decades and unwilling to give it up - it is financial dependent of these cardiovascular events but these events are now largely preventable. It poses a threat to their guaranteed revenue stream. The hospital charges for a heart attack or stroke can easily exceed $150,000, heart bypass surgery over $200,000, stenting over $50,000, etc.     

LDL-c LDL-p Reduction is the Cornerstone of CVD Prevention

Steno-2 showed that lipid management accounts for over 70% reduction of cardiovascular events, diabetes and systolic blood pressure control about 20% each. That has been our experience as well since 2001. 

More Particles, More Plaques

Plaques by their nature want to grow and they do. Some will rupture suddenly and cause these events. Plaques are not affected by what dose of statin or type of statin you are using, only the amount of LDL cholesterol or LDL particles floating in the blood. More LDL cholesterol or LDL particles, more will get into the coronary arteries and into the plaques and fuel the inflammatory process.

Our goal is create our optimal medical therapy barrier so that it keeps our patients on the left side and prevent them from crossing into the right side.

Let us not forget the lessons learned from the COURAGE Trial - titrate statin dose, lower LDLc is better.

COURAGE Trial - Patient Characteristics
COURAGE Trial - The Conclusion

Let us not forget the lessons learned from the COURAGE Trial - not fixing statin dosing but titrating the dose to get to lower LDL-c levels. Otherwise, the results would have been different. The 2013 ACC/AHA guidelines disregarded or forgot the important lesson from this landmark trial and sets us back by more than a decade in our fight against heart disease.

Should patients with chronic stable angina who are already on optimal medical therapy have stenting? In my practice, I only have one patient who experiences angina about once a month relieve by one nitroglycerin. Optimal medical therapy that induces plaque regression also causes angina to eventually disappear. Read about the ORBITA Trial - a landmark trial about chronic stable angina, stenting and placebo effect.

Read about the story behind the NYT anecdote.

© Rolando L. deGoma MD  2018     www.deGomaMD.com     www.AtherosclerosisClinic.com     Capital Cardiology Associates     Allegiance Health Group