Gated myocardial perfusion single photon emission computed tomography in the clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial, Veterans Administration Cooperative study no. 424.
BACKGROUND
Stress gated myocardial perfusion single photon emission computed tomography (gSPECT) is increasingly used before and after intercurrent therapeutic intervention and is the basis for ongoing evaluation in the Department of Veterans Affairs clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial.


RESULTS
The COURAGE trial is a North American multicenter randomized clinical trial that enrolled 2287 patients to aggressive medical therapy vs percutaneous coronary intervention plus aggressive medical therapy. Three COURAGE nuclear substudies have been designed. The goals of substudy 0 are to examine the diagnostic accuracy of the extent and severity of inducible ischemia at baseline in COURAGE patients compared with patient symptoms and quantitative coronary angiography and to explore the relationship between inducible ischemia and the benefit from revascularization when added to medical therapy. Substudy 1 will correlate the extent and severity of provocative ischemia with the frequency, quality, and instability of recurrent symptoms in postcatheterization patients. Substudy 2 (n = 300) will examine the usefulness of sequential gSPECT monitoring 6 to 18 months after therapeutic intervention. Together, these nuclear substudies will evaluate the role of gSPECT to determine the effectiveness of aggressive risk-factor modifications, lifestyle interventions, and anti-ischemic medical therapies with or without revascularization in reducing patients' ischemic burdens.


CONCLUSIONS
The unfolding of evidence on the application of gSPECT in trials such as COURAGE defines a new era for nuclear cardiology. We hope the evidence that emerges from the COURAGE trial will further establish the role of nuclear imaging in the evidence-based management of patients with stable coronary disease.
Shaw
Leslee J
LJ
Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif. 90048, USA.
Heller
Gary V
GV
Casperson
Paul
P
Miranda-Peats
Romalisa
R
Slomka
Piotr
P
Friedman
John
J
Hayes
Sean W
SW
Schwartz
Ronald
R
Weintraub
William S
WS
Maron
David J
DJ
Dada
Marcin
M
King
Spencer
S
Teo
Koon
K
Hartigan
Pamela
P
Boden
William E
WE
O'Rourke
Robert A
RA
Berman
Daniel S
DS
D000465:Algorithms; D017023:Coronary Angiography; D003327:Coronary Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000188:drug therapy*; D006801:Humans; D009206:Myocardium / Q000473:pathology*; D009389:Neovascularization, Pathologic; D010477:Perfusion; D012307:Risk Factors; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D016896:Treatment Outcome; D014728:Veterans