Impact of an Initial Strategy of Medical Therapy Without Percutaneous Coronary Intervention in High-Risk Patients From the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) Trial

David J. Maron, John A. Spertus, G. B.John Mancini, Pamela M. Hartigan, Steven P. Sedlis, Eric R. Bates, William J. Kostuk, Marcin Dada, Daniel S. Berman, Leslee J. Shaw, Bernard R. Chaitman, Koon K. Teo, Robert A. O'Rourke, William S. Weintraub, William E. Boden

Research output: Contribution to journalArticlepeer-review

35 Scopus citations

Abstract

We explored the safety and quality-of-life consequences of treating patients with stable coronary disease and high-risk features initially with optimal medical therapy (OMT) alone compared to OMT plus percutaneous coronary intervention. This was a post hoc analysis of Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial patients. We defined high risk as the onset of Canadian Cardiovascular Society class III angina within 2 months or stabilized acute coronary syndrome within 2 weeks of enrollment. The primary end point was death or myocardial infarction after 4.6 years. Of the 2,287 patients enrolled in the COURAGE trial, 264 (12%) were high risk and had a relative risk of 1.56 for death or myocardial infarction (p = 0.0008) compared to those with non-high-risk features. A total of 35 primary events occurred in the OMT group and 32 in the percutaneous coronary intervention plus OMT group (hazard ratio 1.11, 95% confidence interval 0.69 to 1.79; p = 0.68). No significant difference was found in the prevalence of angina between the 2 groups at 1 year. During the first year of follow-up, 30% of the OMT patients crossed over to the revascularization group. In conclusion, an initial strategy of OMT alone for high-risk patients in the COURAGE trial did not result in increased death or myocardial infarction at 4.6 years or worse angina at 1 year, but it was associated with a high rate of crossover to revascularization.

Original languageEnglish
Pages (from-to)1055-1062
Number of pages8
JournalAmerican Journal of Cardiology
Volume104
Issue number8
DOIs
StatePublished - 15 Oct 2009
Externally publishedYes

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