COURAGE at 25 years: upfront PCI does not reduce death or heart attack in stable coronary disease

Overview

Updated 1 hour ago

For decades, cardiologists have debated whether opening a narrowed artery early in stable coronary disease prevents heart attacks and saves lives. The longest follow-up yet of the COURAGE trial says it does not.

Researchers tracked 959 veterans for a median of 15 years and up to 25 years. The rate of death or heart attack was 91.0% with medical therapy alone and 93.3% with upfront PCI plus medical therapy, a difference small enough to be chance.

Why it matters

For patients with stable coronary disease, the evidence supports starting with medications and lifestyle, not routine early stenting, to prevent death or heart attack.

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Key Indicators

959

Veterans in extended follow-up

42% of the original 2,287 COURAGE participants.

15.0 years

Median follow-up

Maximum follow-up was 25 years.

91.0%

25-year death or heart attack incidence, medical therapy alone

Cumulative incidence in the OMT group.

93.3%

25-year death or heart attack incidence, upfront PCI

Cumulative incidence in the PCI plus OMT group.

1.01

Hazard ratio for death or heart attack

95% CI 0.88–1.15; no significant difference.

54.0% vs 54.6%

25-year heart attack incidence, OMT vs PCI

Cause-specific hazard ratio 1.01; no significant difference.

Voices

Curated perspectives — historical figures and your fellow readers.

People Involved

William E. Boden

Cardiologist and lead investigator of the COURAGE trial

Lead investigator; COURAGE follow-up published

Organizations Involved

Department of Veterans Affairs

Federal agency

Funded COURAGE and supplied linked records for the 25-year follow-up.

The VA runs the largest integrated health care system in the United States and funded the COURAGE trial.

COURAGE trial

Randomized clinical trial

Completed; extended follow-up published in JAMA.

COURAGE compared upfront PCI plus optimal medical therapy with medical therapy alone in stable coronary disease.

JAMA

Medical journal

Published the extended COURAGE follow-up.

JAMA is a peer-reviewed general medical journal published by the American Medical Association.

Timeline

June 1999 November 2026

6 events Latest: Yesterday

Tap a bar to jump to that date

November 2026
JAMA publishes 25-year VA follow-up
Latest Research

No significant difference in death or heart attack with upfront PCI.
Yesterday
March 2020
ISCHEMIA trial reports no primary endpoint difference
Research

An invasive strategy did not reduce cardiovascular events at 3.2 years.
March 2020
November 2015
Extended survival follow-up finds no mortality difference
Research

Up to 15 years of follow-up showed no survival advantage for upfront PCI.
November 12th, 2015
2007
Initial COURAGE results published
Research

At 4.6 years, upfront PCI did not reduce death or heart attack.
2007
January 2004
Enrollment closes with 2,287 patients
Trial milestone

Patients were enrolled at VA and other U.S. hospitals.
January 2004
June 1999
COURAGE begins enrolling patients
Trial start

The trial randomizes patients to upfront PCI plus optimal medical therapy or medical therapy alone.
June 1999

Scenarios

ACC/AHA guideline reaffirms medical therapy first for stable coronary disease

Likely Resolves by End of 2027

Discussed by: COURAGE and ISCHEMIA investigators; guideline committees

The new follow-up adds 25-year data to a body of evidence that already favors medical therapy first. A guideline update would turn that evidence into a formal recommendation against routine upfront PCI for mortality or heart attack reduction.

New trial tests upfront PCI with modern drug-eluting stents

Possible Resolves by End of 2028

Discussed by: JAMA authors, who note COURAGE used mostly bare-metal stents

The JAMA authors point out that COURAGE used mostly bare-metal stents, while modern PCI uses drug-eluting stents that reduce restenosis. A new trial could test whether that changes long-term outcomes.

Pooled analysis confirms no long-term mortality benefit

Possible Resolves by Q2 2028

Discussed by: Cardiology researchers

Combining COURAGE and ISCHEMIA long-term data could strengthen the finding and guide guidelines. The two trials enrolled different risk levels but asked the same core question.

Historical Context

2 moments from history that rhyme with this story — and how they unfolded.

1999-2007

COURAGE trial (2007)

The COURAGE trial randomized 2,287 patients with stable coronary disease to upfront PCI plus optimal medical therapy or medical therapy alone. At a median of 4.6 years, there was no significant difference in death or heart attack.

Then

The result challenged the assumption that early stenting prevented heart attacks.

Now

Guidelines moved toward medical therapy first, with PCI reserved for symptoms or failure of drugs.

Why this matters now

The new 25-year follow-up tests whether that conclusion held over a lifetime.

2020

ISCHEMIA trial (2020)

ISCHEMIA randomized patients with moderate or severe ischemia to an initial invasive strategy or conservative medical therapy. At a median of 3.2 years, the primary endpoint did not differ significantly.

Then

The trial reinforced medical therapy first for stable disease.

Now

Long-term follow-up showed no survival advantage, with a small cardiovascular mortality difference that was not statistically significant.

Why this matters now

It extended the same question to higher-risk patients and set up the long-term follow-up now reported.