Ischemia-Guided Myocardial Revascularization: the Oculo-ischemic Reflex

The COURAGE trial

The most cited clinical trial in that scenario is the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, which has compared randomly and by intention to treat the initial management of stent coronary intervention versus control, and both groups underwent optimized clinical treatment. That study was negative for its primary objective, evidencing identical incidence of death or myocardial infarction in both groups. Thus, the only reason to perform percutaneous coronary intervention in stable disease is to control clinically relevant symptoms.

Regarding the paradigm that revascularization should be performed in case of myocardial ischemia, it is important to assess if the conclusion of the COURAGE trial is valid for ischemia identified on complementary tests. Of the patients undergoing myocardial scintigraphy in the COURAGE trial (61% of that trial sample), 89% had ischemia, and 67% showed ischemia in multiple coronary territories. Because the election of patients to undergo scintigraphy has not been based on disease severity, their data allowed us to infer that the inclusion criteria of the COURAGE trial were sufficient to select patients with a significant ischemic load.

[…]