Predicting outcome in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation): coronary anatomy versus ischemia.
OBJECTIVE
The aim of this study was to determine the relative utility of anatomic and ischemic burden of coronary artery disease for predicting outcomes.


BACKGROUND
Both anatomic burden and ischemic burden of coronary artery disease determine patient prognosis and influence myocardial revascularization decisions. When both measures are available, their relative utility for prognostication and management choice is controversial.


METHODS
A total of 621 patients enrolled in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial with baseline quantitative nuclear single-photon emission computed tomography (SPECT) and quantitative coronary angiography were studied. Several multiple regression models were constructed to determine independent predictors of the endpoint of death, myocardial infarction (MI) (excluding periprocedural MI) and non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Ischemic burden during stress SPECT, anatomic burden derived from angiography, left ventricular ejection fraction, and assignment to either optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) or OMT alone were analyzed.


RESULTS
In nonadjusted and adjusted regression models, anatomic burden and left ventricular ejection fraction were consistent predictors of death, MI, and NSTE-ACS, whereas ischemic burden and treatment assignment were not. There was a marginal (p = 0.03) effect of the interaction term of anatomic and ischemic burden for the prediction of clinical outcome, but separately or in combination, neither anatomy nor ischemia interacted with therapeutic strategy to predict outcome.


CONCLUSIONS
In a cohort of patients treated with OMT, anatomic burden was a consistent predictor of death, MI, and NSTE-ACS, whereas ischemic burden was not. Importantly, neither determination, even in combination, identified a patient profile benefiting preferentially from an invasive therapeutic strategy. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).
University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: mancini@mail.ubc.ca.
G B John
GBJ
Mancini
Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, Connecticut.
Pamela M
PM
Hartigan
Emory University School of Medicine, Atlanta, Georgia.
Leslee J
LJ
Shaw
Cedars-Sinai Heart Institute, University of California, Los Angeles, California.
Daniel S
DS
Berman
Cedars-Sinai Heart Institute, University of California, Los Angeles, California.
Sean W
SW
Hayes
University of Michigan Medical Center, Ann Arbor, Michigan.
Eric R
ER
Bates
Vanderbilt University Medical Center, Nashville, Tennessee.
David J
DJ
Maron
McMaster University Medical Center, Hamilton, Ontario, Canada.
Koon
K
Teo
VA New York Harbor Healthcare System, New York Campus, New York University School of Medicine, New York, New York.
Steven P
SP
Sedlis
St. Louis University Hospital, St. Louis, Missouri.
Bernard R
BR
Chaitman
Christiana Care Health System, Newark, Delaware.
William S
WS
Weintraub
Mid America Heart Institute, University of Missouri, Kansas City, Missouri.
John A
JA
Spertus
London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.
William J
WJ
Kostuk
Hartford Hospital, Hartford, Connecticut.
Marcin
M
Dada
University of Kentucky, Lexington, Kentucky.
David C
DC
Booth
New York Health Care System, Buffalo General Hospital and the State University of New York at Buffalo, Buffalo, New York.
William E
WE
Boden
D000368:Aged; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D003326:Coronary Circulation; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality; D011237:Predictive Value of Tests; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D015899:Tomography, Emission-Computed, Single-Photon; D016896:Treatment Outcome; D016277:Ventricular Function, Left
D002317:Cardiovascular Agents
angiographic burden; coronary angiography; ischemia; ischemic burden; nuclear perfusion imaging; stable ischemic heart disease