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Evevident
Original paper
2007NEJMCardiology

COURAGE

Optimal medical therapy with or without PCI for stable coronary disease

RCTStable CAD

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Overview

In stable CAD, adding PCI to optimal medical therapy did not reduce death or MI compared with medical therapy alone.

Clinical takeaway

COURAGE reframed PCI in stable CAD as mainly symptom-directed rather than prognostic for most patients without high-risk unstable features.

Key result

No significant reduction in death or nonfatal MI with PCI (HR 1.05; 95% CI 0.87-1.27).

Practice impact

Use PCI in stable CAD primarily for refractory symptoms or specific high-risk anatomy, not routine event prevention.

Evidence

Study design

Randomized, open-label, controlled trial.

Enrollment

2,287

Follow-up

Median 4.6 years (range 2.5-7.0).

Geography

United States, Canada

Clinical question

Does PCI plus optimal medical therapy reduce death or MI compared with optimal medical therapy alone in stable CAD?

Population

  • Patients with objective ischemia and significant stable coronary artery disease.

Intervention

PCI plus optimal medical therapy.

Comparator

Optimal medical therapy alone.

Primary outcome

Death from any cause and nonfatal MI.

Adding PCI to optimal medical therapy did not reduce death or nonfatal MI compared with medical therapy alone.

Hazard ratio / 1.05 / CI 95% CI 0.87-1.27 / p=0.62

Key results

  • Primary outcome: 4.6-year cumulative event rate 19.0% with PCI vs 18.5% with medical therapy; HR 1.05; 95% CI 0.87-1.27; p=0.62.
  • No difference in the composite of death, MI, or stroke or in hospitalization for ACS.
  • PCI improved angina relief earlier, but the difference narrowed over time as many medical-therapy patients crossed over to revascularization.

Harms

  • PCI added upfront procedural risk without reducing death or MI.
  • About one third of patients assigned to medical therapy alone eventually required revascularization for symptoms.

Clinical Use

When to cite

  • When explaining why stable coronary artery disease can often start with optimal medical therapy rather than routine PCI for prognosis.

Practice impact

  • Use PCI in stable CAD primarily for refractory symptoms or specific high-risk anatomy, not routine event prevention.

Applicability

  • Most applicable to patients with objective ischemia and significant stable coronary artery disease.

Limitations

  • Bare-metal stent era; predates drug-eluting stents and modern PCI technique.
  • Excluded very high-risk anatomy such as left main disease.
  • Substantial crossover to revascularization occurred in the medical-therapy group.

Common misinterpretations

  • Do not extend COURAGE to acute coronary syndromes or left main disease; it enrolled stable patients.
  • Do not read COURAGE as showing PCI is useless in stable CAD; it improved angina, just not death or MI.

Related evidence

ISCHEMIA - Later TrialFAME 2 - Contrasting Result

Citation

Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516. doi:10.1056/NEJMoa070829

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.