COURAGE

PCI + optimal medical therapy vs medical therapy alone in stable CAD
In stable CAD, routine upfront PCI added to optimal medical therapy did not reduce death or nonfatal MI. PCI improved angina faster, but medical therapy remained the foundation

Study design

  • Multicenter randomized trial
  • 50 US and Canadian centers
  • N = 2,287
  • PCI + optimal medical therapy vs optimal medical therapy alone
  • Median follow-up 4.6 years
  • Primary outcome: all-cause death or nonfatal MI

Population

Included
  • Stable CAD
  • Objective myocardial ischemia
  • Significant coronary disease
  • Suitable for PCI and intensive medical therapy
Not the target population
  • ACS
  • Left main disease requiring revascularization
  • Severe LV dysfunction
  • Unstable or refractory symptoms
  • Anatomy requiring urgent revascularization
Stable CAD Objective ischemia N = 2,287 No ACS Median 4.6 yr

Interventions

PCI + OMT
  • PCI of appropriate coronary lesions
  • Mostly bare-metal stent era
  • Aspirin + clopidogrel when indicated
  • Intensive risk-factor and antianginal therapy
  • n = 1,149
OMT alone
  • Antiplatelet therapy
  • Intensive lipid lowering
  • BP control
  • Antianginal therapy
  • Lifestyle modification
  • n = 1,138

Primary outcome

All-cause death or nonfatal MI
19.0% PCI + OMT vs 18.5% OMT alone
HR 1.05, 95% CI 0.87–1.27, P = 0.62

PCI + OMT vs OMT alone

Death or nonfatal MI

25% 20% 15% 10% 5% 0%
19.0%
PCI + OMT
18.5%
OMT alone
19.0% vs 18.5%  |  HR 1.05  |  95% CI 0.87–1.27  |  P = 0.62

Routine upfront PCI did not reduce death or nonfatal MI

Secondary outcomes

Death

7.6% PCI vs 8.3% OMT
No significant difference

MI

13.2% vs 12.3%
HR 1.13, P = 0.33

Death, MI or stroke

20.0% vs 19.5%
No significant difference

ACS hospitalization

12.4% vs 11.8%
No significant difference

Symptoms

  • PCI produced greater early angina relief
  • Angina improved substantially with medical therapy alone
  • Difference between groups narrowed with longer follow-up
  • More OMT patients eventually required revascularization
PCI still matters: In stable CAD, its main benefit is symptom relief when angina persists despite medical therapy

Clinical interpretation

  • Routine PCI does not reduce death or MI in stable CAD when added to intensive medical therapy
  • Medical therapy is the foundation of treatment
  • PCI is reasonable for persistent lifestyle-limiting angina despite medical therapy
  • Do not extrapolate COURAGE to ACS or anatomy with a separate prognostic indication for revascularization
Think: Stable CAD + manageable symptoms → treat medically first

Limitations

  • Predominantly bare-metal stent era
  • Predates contemporary PCI techniques and newer medical therapies
  • Patients were selected after coronary anatomy was generally known
  • High-risk anatomy and unstable patients were not the population studied
  • Substantial later revascularization occurred in the medical-therapy group
COURAGE tested routine upfront PCI in stable CAD. It does not mean revascularization never improves prognosis, and it does not apply to ACS or other established anatomy-driven indications
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;356:1503–1516. doi:10.1056/NEJMoa070829. NEJM