Ischemia is the critical determinant of revascularization benefit: an interventionalist's perspective of the COURAGE trial.

Although advances in percutaneous catheter-based interventions (PCI) for coronary artery disease have been associated with reductions in angiographic as well as clinical restenosis, no consistent reduction in the occurrence of death or nonfatal myocardial infarction (MI) has been observed either between devices (balloon vs bare-metal stent vs drug-eluting stent [DES]) or between device and medically treated patients with chronic stable coronary disease. Objective evidence of myocardial ischemia--irrespective of the methodology used to demonstrate its presence--is qualitatively and quantitatively related to the occurrence of death and/or nonfatal MI. The magnitude of ischemia is directly proportional to the magnitude of revascularization benefit (reduction in death or MI). Revascularization by PCI is more effective in reducing ischemia than medical therapy alone. The evolution of both PCI technology (DES) and adjunctive pharmacology has improved the relative magnitude and durability of PCI benefit compared with medical therapy alone.