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

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial established that, for patients with stable coronary artery disease (CAD), an initial management strategy of percutaneous coronary intervention plus optimal medical therapy did not reduce the long-term rates of death, myocardial infarction, or other cardiovascular events as compared with optimal medical therapy alone. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial reported that for patients with type 2 diabetes and stable CAD, a strategy of prompt coronary revascularization and intensive medical therapy did not reduce all-cause mortality or the composite of death, myocardial infarction or stroke compared with intensive medical therapy alone; however, in the group of patients appropriate for coronary artery bypass graft surgery (CABG), prompt revascularization with CABG resulted in significantly lower rates of major cardiovascular events, specifically myocardial infarction, than intensive medical therapy alone. The results from these two large multicenter clinical trials have led the medical community to re-evaluate how one should approach and treat patients with CAD and stable ischemic symptoms. In this special issue, experts from several disciplines discuss how the COURAGE and BARI 2D results have affected clinical practice and highlight the key questions that remain unanswered.