Randomized clinical trials have not demonstrated a survival benefit with percutaneous
coronary intervention in stable ischemic heart disease (SIHD). We evaluated the generalizability
of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug
Evaluation) trial findings to the broader population of veterans with SIHD. Veterans
who underwent coronary angiography between 2005 and 2013 for SIHD were identified
from the Veterans Affairs Clinical Assessment, Reporting and Tracking Program (VA
CART). Patient-level comparisons were made between patients from VA CART who met the
eligibility criteria for COURAGE and veterans enrolled in COURAGE between 1999 and
2004. All-cause mortality over long-term follow-up was assessed using Cox proportional
hazards models. COURAGE-eligible patients from VA CART (n = 59,758) were older, had
a higher body mass index, a greater prevalence of co-morbidities, but fewer diseased
vessels on index coronary angiography, and were less likely to be on optimal medical
therapy at baseline and on 1-year follow-up compared with VA COURAGE participants
(n = 968). Patients from VA CART (median follow-up 6.5 years) had higher all-cause
mortality (adjusted hazard ratio [aHR] 1.98 [1.61 to 2.43]) than participants from
VA COURAGE (median follow-up: 4.6 years). Risks of mortality were greater in the 56.4%
patients from CART who were medically managed (aHR 1.94 [1.49 to 2.53]) and in the
43.6% who underwent percutaneous coronary intervention (aHR 1.99 [1.45 to 2.74]),
compared with their respective VA COURAGE arms. In conclusion, in this noncontemporaneous
patient-level analysis, veterans in the randomized COURAGE trial had more favorable
outcomes than the population of veterans with SIHD at large.
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Article Info
Publication History
Published online: July 30, 2022
Received in revised form:
June 19,
2022
Received:
February 7,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Dr. Shah was supported, in part, by the Biomedical Laboratory Research & Development Service of the VA Office of Research and Development, Washington, District of Columbia, iK2CX001074 and the National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, R01HL146206. Dr. Smilowitz is supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K23HL150315.
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Published by Elsevier Inc.
