Optimal Medical Therapy With or Without PCI for Stable Coronary Disease (COURAGE)

COURAGE asked a question that, at the time, felt almost heretical: for stable coronary disease, does opening the blocked artery with a stent actually beat treating the patient with good medication alone?

More than 2,200 patients with stable disease were randomized to PCI plus optimal medical therapy, or optimal medical therapy by itself. Over years of follow-up, there was no significant difference in death, heart attack, stroke, or hospitalization for acute coronary syndrome. Adding the stent to good medical care did not reduce the hard outcomes that matter most. Stenting offered some earlier symptom relief, but it did not prevent events.

The trial reshaped thinking about stable coronary disease, shifting the emphasis toward aggressive medical therapy — statins, blood-pressure control, antiplatelet drugs, lifestyle — as the foundation, with procedures reserved for symptoms that medication cannot control. Its conclusion was later reinforced by the ORBITA and ISCHEMIA trials.

We rate the evidence very strong. A large, well-conducted randomized trial, COURAGE is a landmark that helped separate the treatment of stable disease from the reflex to fix every visible blockage.