Coronary Revascularization in Patients with Stable or Asymptomatic Coronary Artery Disease: A Review of the CouRAge Trial

• Objective: To review the COURAGE trial and other data related to revascularization of patients with asymptomatic or stable coronary artery disease. • Methods: Literature review. • Results: The goals of therapy in patients with stable angina are to alleviate symptoms, prevent future events, and improve survival. This is achieved by a combination of antiplatelet therapy, risk factor modification, antianginal medications, and revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting. The COURAGE trial compared optimal medical therapy plus PCI with bare-metal stenting with optimal medical therapy alone. No significant difference was seen in the rate of death or MI; patients in the PCI group had less angina and 1 and 3 years but not at 5 years and had fewer new revascularizations. • Conclusion: Revascularization in asymptomatic or stable CAD is reasonable in patients who continue to have symptoms despite optimal medical therapy and in patients in whom revascularization may change survival. Patient preferences should be included in decision making. Coronary revascularization with percutaneous coronary intervention (PCI) reduces death and myocardial infarction in acute coronary syndrome [1–5]. It is also effective in the relief of angina and in the improvement of short-term exercise tolerance in patients with chronic ischemic heart disease [6–8]. However, there is no clear evidence that PCI as secondary prevention of stable coronary artery disease improves survival. The recently published Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial is the first to compare contemporary medical therapy with contemporary revascularization techniques [9]. In this article, we review the COURAGE trial and other data related to revascularization of patients with asymptomatic or stable coronary artery disease. clinical context epidemiology Ischemic heart disease is the leading cause of death in the United States [10]. It is responsible for 1 out of every 4.8 deaths [11,12]. More than 1 million people per year suffer a myocardial infarction, and even more require hospitalization and lifestyle limitations as a result of their disease. Even after revascularization, up to 20% of patients do not return to work [13]. Approximately one half of patients with ischemic heart disease initially present with chronic stable angina, a symptom that likely affects more than 6 million people in the United States [14,15]. Left untreated, coronary artery disease can progress to increased myocardial ischemia, myocardial infarction, left ventricular dysfunction, and death. Appropriate management of chronic stable angina is crucial to minimization of morbidity and mortality in coronary heart disease. Pathogenesis Myocardial ischemia occurs from an imbalance between myocardial oxygen supply and demand. The vast majority of chronic ischemic heart disease in industrialized nations is related to coronary atherosclerosis. Plaque and remodeling from the coronary atherosclerotic process forms obstruction within the lumen of coronary arteries and disrupts normal endothelial function. The resulting decrease in myocardial oxygen supply may not be enough to produce symptoms at rest, but activities that increase myocardial oxygen demand may lead to myocardial ischemia and symptoms of angina. Major independent risk factors for coronary heart disease include advanced age, smoking, diabetes mellitus, hyperlipidemia, hypertension, and family history of premature coronary artery disease [16]. Less common potential etiologies of epicardial coronary artery obstruction include coronary vasospasm, congenital abnormalities, vasculitis, From the Division of Cardiovascular Medicine, University of Michigan, Ann