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Clinical implications of the BARI 2D and COURAGE trials: overview

Maria Mori Brooks1, William E Boden, Robert L Frye

  • 1Department of Epidemiology and Biostatistics, University of Pittsburgh, Pennsylvania, USA. mbrooks@pitt.edu

Coronary Artery Disease
|July 29, 2010
PubMed

Insights

For stable coronary artery disease (CAD), the COURAGE trial found percutaneous coronary intervention plus optimal medical therapy did not improve outcomes versus optimal medical therapy alone. The BARI 2D trial showed revascularization did not reduce mortality but CABG lowered major events in select patients.

Area of Science:

  • Cardiology
  • Clinical Trials
  • Interventional Cardiology

Background:

  • The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials are pivotal studies in stable coronary artery disease (CAD).
  • These trials investigated the efficacy of revascularization strategies combined with optimal medical therapy in patients with stable CAD, including those with type 2 diabetes.

Purpose of the Study:

  • To analyze the impact of the COURAGE and BARI 2D trial results on current clinical practice for managing stable coronary artery disease (CAD).
  • To re-evaluate treatment approaches for patients experiencing stable ischemic symptoms, considering the findings from these large-scale clinical trials.
  • To identify and discuss key unanswered questions in the management of CAD following the COURAGE and BARI 2D trials.

Main Methods:

  • The COURAGE trial compared percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) against OMT alone in stable CAD patients.
  • The BARI 2D trial compared prompt revascularization (PCI or CABG) plus intensive medical therapy against intensive medical therapy alone in patients with type 2 diabetes and stable CAD.
  • This special issue synthesizes expert opinions on the clinical implications and remaining questions from these trials.

Main Results:

  • The COURAGE trial demonstrated no significant difference in long-term rates of death, myocardial infarction, or other cardiovascular events between PCI+OMT and OMT alone.
  • The BARI 2D trial found no reduction in all-cause mortality or the composite of death, myocardial infarction, or stroke with prompt revascularization compared to intensive medical therapy alone.
  • However, in the BARI 2D trial, coronary artery bypass graft surgery (CABG) significantly reduced major cardiovascular events, specifically myocardial infarction, compared to intensive medical therapy alone in appropriate patients.

Conclusions:

  • The COURAGE and BARI 2D trial results necessitate a re-evaluation of initial revascularization strategies for stable CAD.
  • While PCI may not offer additional benefits over OMT alone for stable CAD, CABG may be beneficial for select patient groups.
  • Further research is needed to address the remaining questions regarding the optimal management of stable CAD and ischemic symptoms.

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