COURAGE at 25 years

Presented in FS.01 at AHA 2026 (Saturday 7 November) and published as a research letter in JAMA. Post hoc extended observational follow-up of 959 of the 2,287 COURAGE participants (42 percent), the US veterans at 15 VA hospitals who consented to record linkage: 474 randomised to optimal medical therapy alone, 485 to upfront PCI plus OMT. Median follow-up 15.0 years (IQR 8.9 to 21.3, maximum 25.0). Death or MI: 91.0 versus 93.3 percent at 25 years, HR 1.01 (0.88 to 1.15), log-rank P=0.89; death 82.2 versus 83.9 percent, HR 0.98 (0.85 to 1.13); MI 54.0 versus 54.6 percent, HR 1.01; first revascularisation in the OMT arm 53.5 percent versus repeat revascularisation in the PCI arm 50.4 percent, HR 0.87 (0.73 to 1.03). With bare-metal stents of the 2000s and an all-male veteran subset, the signal is the same as in ISCHEMIA: routine upfront PCI for prognosis in stable CAD has no support, even over a quarter century. ISCHEMIA-EXTEND and ISCHEMIA-CKD EXTEND were presented in the same session; their figures are not public yet.