Cracks in the Evidence: Why Studies from COURAGE to ISCHEMIA Failed to Show Benefit of Stenting PCI

Percutaneous Coronary Intervention (PCI) with stenting remains widely utilized for managing Chronic Coronary Syndrome (CCS). However, landmark clinical trials such as COURAGE and ISCHEMIA have repeatedly shown no significant advantage of PCI with stenting over Optimal Medical Therapy (OMT). This review critically analyses methodological limitations, including overlooked Vulnerable Plaques (VPs), Incomplete Revascularization (IR), inherent procedural risks, long-term stent complications, and the consistent lack of mortality benefits. Furthermore, unique challenges in translating these international trial results into the Indonesian healthcare context, such as medication adherence issues, quality disparities in interventional practice, and distinct medico-legal pressures, are discussed. Bethsaida Hospital in Indonesia, led by Prof. Dasaad Mulijono, has successfully addressed these limitations through a pioneering integrated approach combining PCI utilizing Drug-Coated Balloon (DCB) technology, rigorous OMT, and a Whole-Food Plant-Based Diet (WFPBD), resulting in exceptional outcomes, including markedly reduced rates of target lesion revascularization (2%), virtually no myocardial infarctions or PCI-related mortalities, and effective management of VPs. Recognizing these limitations and contextual factors is crucial for informed, individualized CCS treatment decisions. If leading Indonesian cardiology centres can replicate and sustain these strategies, stenting PCI in CCS may be justified.