Do major cardiovascular outcomes in patients with stable ischemic heart disease in the clinical outcomes utilizing revascularization and aggressive drug evaluation trial differ by healthcare system?
BACKGROUND
The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial enrolled patients from 3 distinct healthcare systems (HCSs) in North America. The primary aim of this study was to determine whether there is a treatment difference in cardiovascular outcomes by HCS.


RESULTS
The study population included 968 patients from the US Department of Veterans Affairs (VA), 386 from the US non-VA, and 931 from Canada with different comorbidities and prognoses. The primary outcome was all-cause mortality or nonfatal myocardial infarction (MI) during the median 4.6-year follow-up. Baseline demographics were similar between percutaneous coronary intervention and optimal medical therapy treatment groups within each HCS. After follow-up, the primary end point of total mortality and nonfatal MI was not statistically significant between percutaneous coronary intervention and optimal medical therapy, regardless of HCS: VA, 22.3% versus 21.9% (hazard ratio, 1.05; 95% CI, 0.80-1.38; P=0.95); US non-VA, 15.8% versus 21.8% (hazard ratio, 0.70; 95% CI, 0.43-1.12; P=0.24); Canadian HCS, 17.3% versus 13.5% (hazard ratio, 1.30; 95% CI, 0.93-1.83; P=0.17). The interaction between HCSs and treatment was not statistically significant. Long-term mortality was significantly higher in the VA system as a result of significantly greater comorbidity and worse left ventricular function.


CONCLUSIONS
In the COURAGE trial, addition of percutaneous coronary intervention to optimal medical therapy did not improve 5-year survival or reduce MI or other major adverse cardiovascular events regardless of whether patients were Canadian or American or US veterans or non-veterans. Outcome differences were largely explained by differences in baseline characteristics known to affect long-term prognosis.
Chaitman
Bernard R
BR
Department of Internal Medicine, Saint Louis University School of Medicine, 1034 S Brentwood Blvd., St Louis, MO 63117, USA. chaitman@slu.edu
Hartigan
Pamela M
PM
Booth
David C
DC
Teo
Koon K
KK
Mancini
G B John
GB
Kostuk
William J
WJ
Spertus
John A
JA
Maron
David J
DJ
Dada
Marcin
M
O'Rourke
Robert A
RA
Weintraub
William S
WS
Berman
Daniel S
DS
Shaw
Leslee J
LJ
Boden
William E
WE
D002170:Canada; D015897:Comorbidity; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D018450:Disease Progression; D004358:Drug Therapy / Q000379:methods / Q000401:mortality; D005500:Follow-Up Studies; D006801:Humans; D009203:Myocardial Infarction; D017202:Myocardial Ischemia / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy; D009204:Myocardial Revascularization / Q000379:methods / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy; D014728:Veterans