Angiographic profiles in courage.

T he debate about the role of coronary revascularization on top of optimal medical therapy for patients with obstructive coronary artery disease (CAD) and stable symptoms remains vibrant. Despite significant progress in understanding risk factors for atherosclerosis and altering those risk factors at the level of populations, the " double whammy " of the aging of the population as a whole, coupled with enormous increases in diabetes mellitus and obesity, consign us to decades of continued concern about how to treat documented obstructive CAD. Based on the commonsense notion that " relieving " an obstruction should improve the outcomes of patients with obstructive CAD by opening the artery more freely to flow, a large industry has been built to provide revascularization with coronary bypass surgery and percutaneous coronary intervention (PCI). Countless patients have been led to believe that " fixing " the artery with a stent would prevent heart attack and death. This benefit appears to be a critical part of medical care for patients with ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndromes and in the setting of severe 3-vessel or left main CAD (especially with left ventricular dysfunction). 1,2 However, the appropriate course of action for patients with stable symptoms and less severe CAD continues to be debated. A series of trials, including the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial in particular, have solidified the evidence that emerged from previous smaller trials: for patients with mild or no symptoms, modest CAD, and good left ventricular function, revascularization does not significantly improve survival; furthermore, it has no impact on the risk of death or myocardial infarction (MI)! These empirical findings are so counterintuitive to the commonsense notion of " relieving coronary obstruction " that COURAGE has been subjected to major and persistent attacks on its validity and generalizabil-ity. 3 The report in this issue of Circulation: Cardiovascular Quality and Outcomes by Mancini and colleagues 4 adds significant clarity to some points that have been debated, while leaving other questions for future articles to address. First, the results lay to rest the critique that the revascular-ization procedure itself was suboptimal in COURAGE, especially with regard to the Veterans Health Administration (VHA) system, which enrolled many of the trial's subjects. Although VHA subjects were clearly sicker, with more severe CAD, more prior bypass surgery, and a preponderance of other risk factors, outcomes in the VHA …