Observations From the COURAGE Trial

Background—The extent to which recurrent events in patients with stable coronary artery disease is attributable to progression of an index lesion originally 50% diameter stenosis (DS) but not revascularized or originally 50% DS is unknown during optimal medical therapy (OMT). Methods and Results—In the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 205 patients assigned to OMT plus percutaneous coronary intervention (PCI) and 284 patients assigned to OMT only had symptom-driven angiograms suitable for analysis. Percentages of patients in the OMT PCI and OMT-only cohorts with index lesions originally 50% DS were 30% and 32%, respectively; 20% and 68% had index lesions originally 50% DS. In both groups, index lesions originally 50% or 50% DS represented 4% and 25% of all such lesions, respectively. The only angiographic predictor of myocardial infarction or acute coronary syndrome was the number of lesions originally 50% DS that had not been revascularized (odds ratio, 1.15; confidence limits, 1.01–1.31; P 0.04). Conclusions—Lesions originally 50% DS were index lesions in one third of patients referred for symptom-driven repeat angiography, but represented 4% of all such lesions. Nonrevascularized lesions originally 50% DS were more often index lesions in OMT-only patients, but still represented a minority ( 25%) of all such lesions. These findings underscore the need for improved therapies to arrest plaque progression and reliable strategies for selecting stenoses warranting PCI. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00007657. (Circ Cardiovasc Interv. 2011;4:545-552.)