Optimal Medical Therapy With or Without Percutaneous Coronary Intervention to Reduce Ischemic Burden : Results From the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial Nuclear Substudy

• Published in: Circulation (New York, N.Y.) N.Y.), 2008-03, Vol.117 (10), p.1283-1291
• Main Authors: SHAW, Leslee J, BERMAN, Daniel S, CHAITMAN, Bernard R, FRIEDMAN, John, SLOMKA, Piotr, HELLER, Gary V, GERMANO, Guido, GOSSELIN, Gilbert, BERGER, Peter, KOSTUK, William J, SCHWARTZ, Ronald G, KNUDTSON, Merill, MARON, David J, VELEDAR, Emir, BATES, Eric R, MCCALLISTER, Benjamin, TEO, Koon K, BODEN, William E, MANCINI, G. B. John, HAYES, Sean W, HARTIGAN, Pamela M, WEINTRAUB, William S, O'ROURKE, Robert A, DADA, Marcin, SPERTUS, John A
• Format: Article
• Language: English
• Subjects: Aged; Angioplasty, Balloon, Coronary; Biological and medical sciences; Blood and lymphatic vessels; Blood. Blood coagulation. Reticuloendothelial system; Cardiology. Vascular system; Combined Modality Therapy; Coronary Angiography; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Exercise Test; Female; Humans; Kaplan-Meier Estimate; Male; Medical sciences; Middle Aged; Myocardial Ischemia - diagnosis; Myocardial Ischemia - drug therapy; Myocardial Ischemia - therapy; Myocardial Revascularization - methods; Pharmacology. Drug treatments; Proportional Hazards Models; Single-Blind Method; Tomography, Emission-Computed, Single-Photon; Treatment Outcome
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.107.743963

Extent and severity of myocardial ischemia are determinants of risk for patients with coronary artery disease, and ischemia reduction is an important therapeutic goal. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) nuclear substudy compared the effectiveness of percutaneous coronary intervention (PCI) for ischemia reduction added to optimal medical therapy (OMT) with the use of myocardial perfusion single photon emission computed tomography (MPS). Of the 2287 COURAGE patients, 314 were enrolled in this substudy of serial rest/stress MPS performed before treatment and 6 to 18 months (mean=374+/-50 days) after randomization using paired exercise (n=84) or vasodilator stress (n=230). A blinded core laboratory analyzed quantitative MPS measures of percent ischemic myocardium. Moderate to severe ischemia encumbered > or = 10% myocardium. The primary end point was > or = 5% reduction in ischemic myocardium at follow-up. Treatment groups had similar baseline characteristics. At follow-up, the reduction in ischemic myocardium was greater with PCI+OMT (-2.7%; 95% confidence interval, -1.7%, -3.8%) than with OMT (-0.5%; 95% confidence interval, -1.6%, 0.6%; P or = 10% residual ischemia on follow-up MPS (P=0.002 [risk-adjusted P=0.09]). In COURAGE patients who underwent serial MPS, adding PCI to OMT resulted in greater reduction in ischemia compared with OMT alone. Our findings suggest a treatment target of > or = 5% ischemia reduction with OMT with or without coronary revascularization.