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~~~~~~~~~~~~~~~~  !  ';  P+sZCU 4  3@)#=c6N3!Rl +; M.+ - =3!a a      a  $" &r<dH  5$'?98\ <s"   :~L / S   T ,>+ !I,#   $ "$  <-#F7 ;;%&()*+,-hb$s#ڿE`"  P b$$>I$ P b$-gB4nyө* P "$ˏqv[9tP $P b$n0P 2$I&"!*Ra4P "$;W[-L9P "$Qq_}yNqUeUP "$ҷbPs_PqP "$Do*a֩jC5t! P "$U JgI [P "$>hx=_Wk$zP "$zCU>hx jP  n0e0e     A5% 8c8c     ?A)BCD|E||S" @> ʚ;>7ʚ;g4BdBdv 0Jpp<4!d!d` 0L >M <4dddd` 0L >M  <4dddd 0Lhg4=d=dv 0.p po___PPT9%hlpL.55555z? %O =UhLa angioplastia coronariaen pacientes con angina estableno previene el infarto ni reduce la mortalidadii$fff Z  AntecedentesLa angioplastia coronaria (APC) se ha mostrado eficaz para reducir la mortalidad y la incidencia de infarto de miocardio (IM) en pacientes con sndrome coronario agudo. No se ha demostrado para personas con enfermedad coronaria estable. Se han publicado pocos estudios en pacientes en esta situacin y la mayor parte se llevaron a cabo antes de que fuese habitual la utilizacin de stents y de que fuesen habituales los cuidados actuales. *4, o4  ObjetivosEstudiar si la APC asociada al tratamiento mdico ptimo (TMO) reduce el riesgo de muerte y de IM no fatal en pacientes con enfermedad coronaria estable. Diseo (1)|Ensayo clnico (COURAGE - Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation). Criterios de inclusin: personas con angina de pecho estable y una estenosis proximal e"70% ene"1 arteria coronaria y evidencia de isquemia miocrdica en el ECG de esfuerzo o de reposo o e"80% con clnica tpica. VL,< # Diseo (2) NCriterios de exclusin: isquemia clase IV de la Canadian Cardiovascular Society, prueba de esfuerzo marcadamente positiva, insuficiencia cardaca refractaria o antecedentes de shock cardiognico, fraccin de eyeccin <30%, revascularizacin coronaria en los 6 meses previos o anatoma coronaria que no permitiese la angioplastia.676t/ ; L  Diseo (3)Los participantes fueron distribuidos aleatoriamente a recibir: TMO: aspirina (85-325 mg/d) o clopidogrel, metoprolol, amlodipino, mononitrato de isosorbide, lisinipril o losartn y simvastatina sola o con ezetimibe hasta conseguir niveles de colesterol LDL de 60-85 mg/dL y ejercicio, niacina o fibratos para elevar el colesterol HDL y controlar los triglicridos. TMO + APC con stent. En los ltimos 6 meses los stent fueron farmacolgicamente activos.@ZZ/ZYZ@/$:%"         3 K $ Diseo (4)BLos resultados del tratamiento fueron valorados por investigadores que desconocan el grupo de tratamiento al que haban sido asignados los pacientes. Variables de resultado: Principal: combinacin de muerte por cualquier causa e IM. Secundaria: combinacin de los anteriores, AVCy hospitalizacin por angina inestable.4Resultados (1)%Resultados (2) Se pudo hacer una APC en el 88% de los pacientes asignados a ese tratamiento. En el 94% se colocaron stents. El tratamiento mdico recibido fue similar para los dos grupos. A los 5 aos de seguimiento un 70% de los participantes tenan un colesterol LDL<85 mg/dL.* e,dResultados (3)  Resultados (4)En la nica variable en la que se detectaron diferencias importantes fue en la prctica de revascularizaciones posteriores, habitualmente por angor con mala respuesta al tratamiento mdico mximo, que fue ms frecuente en el grupo de tratamiento mdico (21,1 frente a 32,6%; P<0,001). En el anlisis de subgrupos no se detect ninguno en el que la APC mejorase los resultados del TMO. ZZ ConclusionesLos autores concluyen que en en pacientes con enfermedad coronaria estable, la APC aadida al tratamiento mdico ptimo no mejora los resultados en trminos de muerte, infarto de miocardio ni otros eventos cardiovasculares mayores. gComentario (1)La APC en el tratamiento de los sndromes coronarios agudos ha demostrado reducir el riesgo de infarto de miocardio y de angina grave y los ingresos hospitalarios y es probable que reduzca la mortalidad a largo plazo. Estos resultados se han extrapolado a los pacientes con angina estable y es bastante habitual llevar a cabo una coronariografa en estos pacientes y proceder a una revascularizacin en caso de detectarse lesiones susceptibles de tratamiento. Sin embargo, existen pocos estudios llevados a cabo en estos pacientes.Z,I$TComentario (2)Un metaanlisis en el que se revisaban sus resultados no detect ninguna reduccin en el riesgo de muerte ni de infarto de miocardio, aunque s en el riesgo de angina a largo plazo. Los resultados de este trabajo son consistentes con los de dicho metaanlisis. No se demostr ninguna ventaja en trminos de eventos cardiovasculares mayores ni globalmente ni en ninguno de los subgrupos analizados.,  Comentario (3)Cmo puede explicarse esta discrepancia entre los pacientes con angina estable y los pacientes con sndromes coronarios agudos? Es probable que este hecho se deba a que las lesiones que ocasionan angina son ms estables que las que ocasionan un sndrome coronario agudo, por lo que se benefician menos de la intervencin. En ausencia de un beneficio claro, se debe ser muy prudente a la hora de indicar una revascularizacin en pacientes con angor estable.!/3456= > ? ALPQR&S'T(U  ` ` ̙33` 333MMM` ff3333f` f` f` 3` >?" dd@(|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> !(  #  6J  "P<$ 0 J  k7Haga clic para modificar el estilo de ttulo del patrn8 8i  0J  "<$ 0 J  kHaga clic para modificar el estilo de texto del patrn Segundo nivel Tercer nivel Cuarto nivel Quinto nivel7    l  S fAHI:\Apaldia-Usuarios\img\apaldia.gif"nP %!0  6J fff "  5!0 uIAP al da [ http://www.apaldia.com/resumenes/resumen.php?idresumen=450 ]J:  t   H  0޽h ? *Diseo predeterminado0 P +(      0DE  O3  E  R*     0E   3 E  T*  d   c $ ?po  E /   05E  e @1 E  kHaga clic para modificar el estilo de texto del patrn Segundo nivel Tercer nivel Cuarto nivel Quinto nivel7    l   6lE  O  E  R*     6 iE    E  T*  H   0whg ? ̙33 p@@(  @ @ 0&J  O3  J  @*  @ 0@E   3 J  B*  @ 6Xy9  O  J  @*  @ 6z9    E  B* H @ 0whg ? ̙33}  - % 0 " (    s rAHL Y?I:\Apaldia-Usuarios\img\apaldia.gifP3  c $M `0<$ 0 M    6|J fff "  5!0 uIAP al da [ http://www.apaldia.com/resumenes/resumen.php?idresumen=450 ]J:  t     <J   00 <$ 0 J    0PJ ? ?" `  ,$ 0 *Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al for the COURAGE Trial Research Group. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med2007;356: 1503-1516. @ mJ&      c A`C:\Inetpub\wwwroot\Apaldia-Usuarios\img\PDF.GIF uP  5!0 ! c A\C:\Inetpub\wwwroot\Apaldia-Usuarios\img\R.GIF `  P  5!0 " c A^C:\Inetpub\wwwroot\Apaldia-Usuarios\img\TC.GIF R @P  5!0H  0޽h ? ̙33  `P(  r  S E P  E    S E <$ 0 E  H  0޽h ? ̙33  L\(  Lx L c $J P  J   L c $<E <$ 0 E  H L 0޽h ? ̙33:  z(  x  c $.E P  E    c $ 9 <$ 0 E  *.ZH  0޽h ? ̙33 S  $(   r  S p_9 P  J  r  S v9  9  H  0޽h ?  A  P(   r  S  9 P  9    S 9 Pp<$ 0 9  H  0޽h ?  T  $(   r  S \E P  E  r  S tX4 4 H  0޽h ?  Q nf (   x  c $9 P  9  l   ,$D 0Z   s *  2  fA 5?  5 9   0\9  ,$D 0 Caractersticas iniciales de los asignados a los dos grupos fueron similares: Edad media: 61 aos. Un 85% eran varones. Tiempo medio transcurrido desde el inicio de los sntomas hasta la asignacin del tratamiento: 5 meses. Un 67% estaban en estadio I-II. Se repartan ms o menos en terceras partes los pacientes que tenan enfermedad de 1, 2 y 3 vasos. 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