It has not been clearly established whether percutaneous coronary intervention ( PCI) can provide an incremental benefit in quality of life over that provided by. tee and the members of the COURAGE. Trial Executive Committee are provided in the Supplementary Appendix, avail- able at was evaluated in the Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) trial, in which patients were randomly.

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Between andwe assigned patients to undergo PCI with optimal medical therapy PCI group and to receive optimal medical therapy alone medical-therapy group. On the basis of FAME 2, one would need nejn perform PCI in stable patients to prevent 9 urgent revascularizations — only 4 of which have positive biomarkers or ECG changes — without reducing the incidence of death or MI.

At a median follow-up of 4. Also, survival advantage has been demonstrated for revascularization, and particularly with CABG for important patient subgroups—this is based mainly on anatomic features, despite stable symptomatology.

We conducted a randomized trial involving patients who had objective evidence of myocardial ischemia and significant coronary artery disease at 50 U. Women Nwjm Shortchanged Dr.

During a mean follow up of 4. Enter the email you used to register to reset couragr password. You need to document perfusion defect with Myocardial Perfusion Imaging Stress Thallium as popularly known and of course take into account the clinical evaluation of the individual patient.

Boden WE et al. With an anticipated 8, subjects followed for an average of 3. The primary endpoint was a composite of death, MI, or urgent revascularization. If COURAGE had included frial procedures as part of its nrjm endpoint, there would have been significantly more endpoint events in the medical therapy group at a comparable time period. Freedom from angina at 60 months was similar in men and women regardless of treatment strategy.

These are the most important components of the FAME 2 primary endpoint composite. In the NEJM paper, the researchers reported an unadjusted hazard ratio of 0.

As noted by Dr. Revascularization at the drop of the hat became the in thing for interventional cardiologists, without taking into consideration the importance of collateral circulation, degree of coronary reserve and the risk of reperfusion injury. Breaking News Cardiology Journal Club. This randomization process will reduce referral bias. Thursday, September 13, – Two thirds of the patients had multi-vessel disease. The difference was driven by a lower rate of urgent revascularization in the PCI group than in the medical-therapy group see Table.


The COURAGE Trial: PCI is not superior to medical therapy in patients with stable coronary disease

The results from the study are surprising and somewhat unexpected. What I find surprising is the surprised reaction of many commentators. Comment in N Engl J Med. In both trials there was no difference between treatment groups in the incidence of death or MI.

Women also had higher LVEF, fewer diseased coronary vessels, and higher baseline HDL but worse kidney function and a slightly longer duration of angina. Recruitment was halted prematurely after enrollment of patients randomized and enrolled in the registry because of a significant between-group difference in the percentage of patients who had a primary endpoint event: Boden and colleagues compared outcomes by patient sex and treatment assignment after adjustment for relevant baseline characteristics.

The results of one of the more remarkable studies from the meeting of the American College of Cardiology were nemm on Monday, along with the simultaneous early publishing of the study online in the New England Journal of Medicine. If other, ndjm specify.

COURAGE – Wiki Journal Club

N Engl J Med Mar 27; [pub ahead of print]. As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. Boden reports no relevant conflicts of interest. Half of the patients undergoing urgent revascularization had no objective evidence of ischemia i. SAQ angina frequency score improved equally for both sexes over time with either treatment, although OMT patients overall improved less than those who also received PCI.

Knowing the coronary anatomy may have been a driver of early revascularization procedures in the medical therapy groups of both trials. Submit a Question for the Panel Optional. Optimal medical therapy with or without percutaneous coronary intervention in women with stable coronary disease: In FAME 2, I hope this study will raises public awareness of the routine overuse of revascularization as a primary treatment modality for coronary heart disease. Hospitalization for heart failure, even though it was not a prespecified endpoint, is an outcome of interest because it has been shown to powerfully predict adverse outcomes in patients with stable CAD and preserved ejection fraction, he commented.


There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, and stroke All secondary outcomes and individual components of the primary outcomes showed no significant differences between the study groups.

Patients in whom all stenoses had an FFR of more than 0. N Engl J Med. The COURAGE Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial was a randomized trial involving patients with stable but significant coronary artery disease who were randomized to either undergo PCI using bare metal stents or to receive optimal medical therapy alone. Therefore, patients were clinically referred for cath and neither the physicians nor investigators were blinded to the coronary anatomy of patients randomized to the medical-therapy group.

In patients with stable coronary artery disease, it remains unclear whether an initial management strategy of percutaneous coronary intervention PCI with intensive pharmacologic therapy and lifestyle intervention optimal medical therapy is superior to optimal medical therapy alone in reducing the risk of cardiovascular events. The authors of the study explain their results, in part, by the physiologic differences between vulnerable plaques which rupture and are associated with acute coronary syndromes and more fibrous plaques that can cause luminal narrowing and anginal symptoms in patients with stable disease such as those in enrolled in this study.

Compared with men enrolled in COURAGE, women were older 64 vs 62 years oldmore likely to be white and to have a family history of CAD, and less likely to have had prior revascularization. The new adjusted analysis, Dr.

This study is consistent with everything we know about chronic stable coronary heart disease, i.