title: Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention.
abstract: BACKGROUND
  The COURAGE trial reported similar clinical outcomes for patients with stable ischemic heart disease (SIHD) receiving optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI). The current post hoc substudy analysis examined the relationship between baseline stress myocardial ischemia and clinical outcomes based on randomized treatment assignment.
  
  
  METHODS
  A total of 1,381 randomized patients (OMT n = 699, PCI + OMT n = 682) underwent baseline stress myocardial perfusion single-photon emission computed tomographic imaging. Site investigators interpreted the extent of ischemia by the number of ischemic segments using a 6-segment myocardial model. Patients were divided into those with no to mild (<3 ischemic segments) and moderate to severe ischemia (≥ 3 ischemic segments). Cox proportional hazards models were calculated to assess time to the primary end point of death or myocardial infarction.
  
  
  RESULTS
  At baseline, moderate to severe ischemia occurred in more than one-quarter of patients (n = 468), and the incidence was comparable in both treatment groups (P = .36). The primary end point, death or myocardial infarction, was similar in the OMT and PCI + OMT treatment groups for no to mild (18% and 19%, P = .92) and moderate to severe ischemia (19% and 22%, P = .53, interaction P value = .65). There was no gradient increase in events for the overall cohort with the extent of ischemia.
  
  
  CONCLUSIONS
  From the COURAGE trial post hoc substudy, the extent of site-defined ischemia did not predict adverse events and did not alter treatment effectiveness. Currently, evidence supports equipoise as to whether the extent and severity of ischemia impact on therapeutic effectiveness.
authors.affiliation: Emory University School of Medicine, Atlanta, GA 30306, USA. leslee.shaw@emory.edu
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.forename: William S
authors.initials: WS
authors.lastname: Weintraub
authors.forename: David J
authors.initials: DJ
authors.lastname: Maron
authors.forename: Pamela M
authors.initials: PM
authors.lastname: Hartigan
authors.forename: Rory
authors.initials: R
authors.lastname: Hachamovitch
authors.forename: James K
authors.initials: JK
authors.lastname: Min
authors.forename: Marcin
authors.initials: M
authors.lastname: Dada
authors.forename: G B John
authors.initials: GB
authors.lastname: Mancini
authors.forename: Sean W
authors.initials: SW
authors.lastname: Hayes
authors.forename: Robert A
authors.initials: RA
authors.lastname: O'Rourke
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.forename: William
authors.initials: W
authors.lastname: Kostuk
authors.forename: Gilbert
authors.initials: G
authors.lastname: Gosselin
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Chaitman
authors.forename: Merill
authors.initials: M
authors.lastname: Knudtson
authors.forename: John
authors.initials: J
authors.lastname: Friedman
authors.forename: Piotr
authors.initials: P
authors.lastname: Slomka
authors.forename: Guido
authors.initials: G
authors.lastname: Germano
authors.forename: Eric R
authors.initials: ER
authors.lastname: Bates
authors.forename: Koon K
authors.initials: KK
authors.lastname: Teo
authors.forename: William E
authors.initials: WE
authors.lastname: Boden
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D002317:Cardiovascular Agents / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis* / Q000628:therapy*; D055414:Myocardial Perfusion Imaging; D016016:Proportional Hazards Models; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents