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COURAGE 5 years on: the message grows stronger
  1. William E Boden
  1. Correspondence to Dr William E Boden, Department of Medicine, Samuel S. Stratton VA Medical Center, Albany Medical Center, Albany, NY 12208, USA; william.boden{at}va.gov

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Since the advent of percutaneous coronary intervention (PCI) 35 years ago,1 a remarkable and sustained evolution of this catheter-based technology has shifted the treatment of patients with coronary artery disease (CAD) largely away from an initial pharmacological approach to one that emphasises an anatomically-driven management strategy. We now know that non-flow-limiting coronary stenoses are the principal progenitors of most ‘hard’ clinical events, and that total or subtotal coronary occlusion following plaque rupture or fissuring is a cardiovascular emergency that cannot be optimally managed with medication alone. Thus, when patients with ST segment elevation myocardial infarction (STEMI) or high-risk non-STEMI present to the hospital and are often triaged immediately for diagnostic coronary angiography, clinical decision-making is frequently simple and straightforward.2 ,3 Emergent/early PCI has significant proven clinical benefits in acute coronary syndromes (ACS),4–7 and in this setting, the interventional cardiologist's role as the ‘gatekeeper’ for the cardiac catheterisation laboratory is largely centred on facilitating expeditious access to prompt coronary reperfusion and treating culprit stenoses responsible for the acute event. Given the unassailable superiority of PCI in this context, it is appropriate that the interventional cardiologist functions both as diagnostician and ‘therapeuticist’.

However, for patients with multivessel angiographic CAD in the setting of chronic angina or stable ischaemic heart disease (SIHD), clinical pathways have become more complex in recent times, largely due to three landmark trials. In the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, 1800 patients with three-vessel or left main CAD, determined to be equally amenable to coronary-artery bypass grafting (CABG) or PCI with a drug-eluting stent, were randomly assigned to either treatment and followed for 12 months for a non-inferiority comparison.8 The primary endpoint was a composite of major adverse cardiac or cerebrovascular events, so-called Major Adverse Cardiac and Cerebrovascular Events (MACCE) that …

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