The COURAGE Trial: Comparing Stent Therapy vs Optimal Medical (Cholesterol) + Stent Therapy

In 1988, when Ambrose published his findings that most heart attacks involved arteries with less than 50% narrowing, we should have started to re-examine our pre-occupation on stenting the 70% stenosis in the hope of preventing a heart attack.

Other serial angiographic studies have confirmed these findings. 68% of all heart attacks are due to plaque rupture of coronary arteries with less than 50% stenosis. Only 14% have more than 70% stenosis.

We are still not getting it right. Why are too many stents deployed and not enough treatment directed towards the prevention plaque rupture using optimal lipid therapy?

For several years, many experts had called for more aggressive preventive medical therapy and less aggressive preventive interventional therapy. This is based on science - a vast majority of heart attacks are caused of rupture of unstable plaque, not the narrowed artery that the stents open up. An extensive review of the medical literature supported this recommendation.

But the trend continues. In 2003, 1,000,000 stent were deployed; 85% were elective.

COURAGE trial answered a simple question - Is preventive stent therapy really necessary as the initial management of stable CHD patients, even those with extensive multivessel disease, inducible myocardial ischemia and angina? The answer is NO.

The patients in the study were carefully chosen to include only those with really advanced but stable disease as described above. Based on the trial design and patient selection, the PCI group was expected to show a significant benefit over medical therapy alone.

The result showed that in stable CHD patients, preventive PCI was not beneficial when added to optimal preventive medical therapy. This result surprised many.

The landmark result of the COURAGE trial presents an opportunity for change that is long overdue - more emphasis on widespread implementation of the NCEP guidelines, particularly, optimal cholesterol therapy. A shift from aggressive preventive stent therapy to optimal  preventive medical (cholesterol) therapy.

PCI's lack of benefit is because PCI does not prevent rupture of unstable plague. Optimal cholesterol therapy does.