COURAGE TRIAL

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COURAGE TRIAL
Clinical Outcomes Utilising Revascularization and
Aggressive Drug Evaluation
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BACKGROUND In patients with stable coronary
disease, it ramains unclear whether an intial
managemnt Strategy of percutaneous coronary
intervention(PCI) with intensive pharmacologic
therapy and lifestyle intervention(optimal
medical therapy)is superior to optimal medical
therapy alone in reducing the risk of
cardiovacsular events.PCI reduces incidence of
death and MI inpatients with acute coronary
syndromes but similar benefit has not been shown
with stable coronary artery disease. The COURAGE
trial was desighned to determine whethar PCI
coupled optimal medical therapy reduces risk
death and nonfatal MI in patients with stable
coronary artety disease compared with optimal
medical therapy alone
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• METHODS
• Randomised control trial
• 2287 patients-us and canada
• 1149- PCI and medical treatment
• 1138 medical therapy alone
• Primary outcome-death from any cause and nonfatal
  MI durind follow up of 2.5 to 7 years

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• STYDY POPULATION
• Stable coronary artery disease and those in whom
  initial ccs clas iv angina subsequently
  stabilised medically were included

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• ENTRY C RITERIA
• Stenosis of atleast 70 in atleast one proximal
  epucardial coronary artery and objective e/o
  ischemiaor atleast one coronary stenosis of
  atleast 80 and classic angina without
  provocating test
• EXCLUSION CRITERIA
• Persistent class iv angina
• Markedly positive stress test
• Refractory hear failure
• EFlt35

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• TREATMENT
• All patients-aspirin/clopidrogel
• Pci-aspirin clopidrogel
• Antiischemic treatment-longacting metoprolol,
  amlodepine, isosorbide mononitartae alone in
  combination
• Aggressive treatment(simva/- ezetemibe) to lower
  LDL cholestrol(1.55to 2.20)
• Attempt to raise HDL with exercise, extended
  relase niacin, fibrates

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• RESULTS
• Primary event rate-19 in pci group
• And 18.5 in medical group
• Rate of hospitalisation for acute coronary
  syndrome-no sig diff
• Stroke-no significant diff
• 21.1 of patients in pci grouphad aditional
  revascularisation as compared with 32.6 of those
  in medical therapy-revascularisation was
  performed for angina that was unresponsive to
  maximum medical treatment or objective e/o
  worsening ischemia

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• DISCUSSION
• Pci added to optimal medical therapy did not
  reduce the primary composite endpoint of death
  and nonfatal mi or reduace major CV events
  compared to medical treatment alone despite of
  high baseline prevalence of clinical coexisting
• Degree of angina relief was higher in pci group
• Treatment target
• Limitations-85 men, 14 non white

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• PCI????