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Original Articles

Quantitative Results of Baseline Angiography and Percutaneous Coronary Intervention in the COURAGE Trial

G.B. John Mancini, MD; Eric R. Bates, MD; David J. Maron, MD; Pamela Hartigan, MPH, PhD; Marcin Dada, MD; Gilbert Gosselin, MD; William Kostuk, MD; Steven P. Sedlis, MD; Leslee J. Shaw, PhD; Daniel S. Berman, MD; Peter B. Berger, MD; John Spertus, MD, MPH; Kreton Mavromatis, MD; Merril Knudtson, MD; Bernard R. Chaitman, MD; Robert A. O'Rourke, MD; William S. Weintraub, MD; Koon Teo, MB, PhD; William E. Boden, MD on behalf of the COURAGE Trial Investigators and Coordinators

From the Vancouver Hospital, Cardiovascular Imaging Research Core Laboratory (G.B.J.M.), University of British Columbia, Vancouver, Canada; University of Michigan Medical Center (E.R.B.), Ann Arbor; Vanderbilt University Medical Center (D.J.M.), Nashville, Tenn; Veterans Affairs Cooperative Studies Program Coordinating Center (P.H.), Connecticut VA Healthcare System, West Haven, Conn; Hartford Hospital (M.D.), Hartford, Conn; Montreal Heart Institute (G.G.), University of Montreal, Canada; London Health Sciences Centre (W.K.), University of Western Ontario, London, Ontario, Canada; VA New York Harbor Health Care System New York Campus (S.P.S.), New York University School of Medicine; Emory University School of Medicine (L.J.S., K.M.), Atlanta, Ga; Cedars-Sinai Heart Institute (D.S.B.), University of California, Los Angeles; Geisinger Medical Center (P.B.B.), Danville, Pa; Mid-America Heart Institute (J.S.), University of Missouri, Kansas City; University of Calgary (M.K.), Alberta, Canada; St. Louis University Hospital (B.R.C.), St. Louis, Mo; South Texas Veterans Healthcare System and University of Texas Health Science Center at San Antonio (R.A.O.), Tex; Christiana Care Health System (W.S.W.), Newark, Del; McMaster University Medical Centre (K.T.), Hamilton, Ontario, Canada; and Buffalo General Hospital/Kaleida Health (W.E.B.), School of Medicine and Biomedical Sciences, State University of New York.

Correspondence to G.B. John Mancini, MD, Vancouver Hospital, 10209-2775 Laurel Street, Vancouver, British Columbia, Canada, V5Z 1M9. E-mail mancini{at}interchange.ubc.ca

Received October 19, 2008; accepted April 1, 2009.

Background— COURAGE compared outcomes in stable coronary patients randomized to optimal medical therapy plus percutaneous coronary intervention (PCI) versus optimal medical therapy alone.

Methods and Results— Angiographic data were analyzed by treatment arm, health care system (Veterans Administration, US non–Veterans Administration, Canada), and gender. Veterans Administration patients had higher prevalence of coronary artery bypass graft surgery and left ventricular ejection fraction 50%. Men had worse diameter stenosis of the most severe lesion, higher prevalence of prior coronary artery bypass graft surgery, lower left ventricular ejection fraction, and more 3-vessel disease that included a proximal left anterior descending lesion (P<0.0001 for all comparisons versus women). Failure to cross rate (3%) and visual angiographic success of stent procedures (97%) were similar to contemporary practice in the National Cardiovascular Data Registry. Quantitative angiographic PCI success was 93% (residual lesion <50% in-segment) and 82% (<20% in-stent), with only minor nonsignificant differences among health care systems and genders. Event rates were higher in patients with higher jeopardy scores and more severe vessel disease, but rates were similar irrespective of treatment strategy. Within the PCI plus optimal medical therapy arm, complete revascularization was associated with a trend toward lower rate of death or nonfatal myocardial infarction. Complete revascularization was similar between genders and among health care systems.

Conclusions— PCI success and completeness of revascularization did not differ significantly by health care system or gender and were similar to contemporary practice. Angiographic burden of disease affected overall event rates but not response to an initial strategy of PCI plus optimal medical therapy or optimal medical therapy alone.

Key Words: coronary angiography • ventricular ejection fraction • gender identity • delivery of health care • revascularization • stent

Guest Editor for this article was Brahmajee K. Nallamothu, MD.

The online-only Data Supplement is available at http://circoutcomes.ahajournals.org/cgi/content/full/10.1161/CIRCOUTCOMES.108.830091/DC1.

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