{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T20:50:03Z","timestamp":1792615803608,"version":"4.5.0"},"reference-count":31,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"4","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Cardiovascular Quality and Outcomes"],"published-print":{"date-parts":[[2013,7]]},"abstract":"<jats:sec>\n            <jats:title>Background\u2014<\/jats:title>\n            <jats:p>In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, some patients with stable ischemic heart disease randomized to optimal medical therapy (OMT) crossed over to early revascularization. The predictors and outcomes of patients who crossed over from OMT to revascularization are unknown.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods and Results\u2014<\/jats:title>\n            <jats:p>We compared characteristics of OMT patients who did and did not undergo revascularization within 12 months and created a Cox regression model to identify predictors of early revascularization. Patients\u2019 health status was measured with the Seattle Angina Questionnaire. To quantify the potential consequences of initiating OMT without percutaneous coronary intervention, we compared the outcomes of crossover patients with a matched cohort randomized to immediate percutaneous coronary intervention. Among 1148 patients randomized to OMT, 185 (16.1%) underwent early revascularization. Patient characteristics independently associated with early revascularization were worse baseline Seattle Angina Questionnaire scores and healthcare system. Among 156 OMT patients undergoing early revascularization matched to 156 patients randomized to percutaneous coronary intervention, rates of mortality (hazard ratio=0.51 [0.13\u20132.1]) and nonfatal myocardial infarction (hazard ratio=1.9 [0.75\u20134.6]) were similar, as were 1-year Seattle Angina Questionnaire scores. OMT patients, however, experienced worse health status over the initial year of treatment and more unstable angina admissions (hazard ratio=2.8 [1.1\u20137.5]).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion\u2014<\/jats:title>\n            <jats:p>Among COURAGE patients assigned to OMT alone, patients\u2019 angina, dissatisfaction with their current treatment, and, to a lesser extent, their health system were associated with early revascularization. Because early crossover was not associated with an increase in irreversible ischemic events or impaired 12-month health status, these findings support an initial trial of OMT in stable ischemic heart disease with close follow-up of the most symptomatic patients.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Clinical Trial Registration\u2014<\/jats:title>\n            <jats:p>\n              URL:\n              <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"http:\/\/www.clinicaltrials.gov\">http:\/\/www.clinicaltrials.gov<\/jats:ext-link>\n              . Unique identifier: NCT00007657.\n            <\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/circoutcomes.113.000139","type":"journal-article","created":{"date-parts":[[2013,7,10]],"date-time":"2013-07-10T04:52:19Z","timestamp":1373431939000},"page":"409-418","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":32,"title":["Frequency, Predictors, and Consequences of Crossing Over to Revascularization Within 12 Months of Randomization to Optimal Medical Therapy in the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial"],"prefix":"10.1161","volume":"6","author":[{"given":"John A.","family":"Spertus","sequence":"first","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David J.","family":"Maron","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David J.","family":"Cohen","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Kolm","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pam","family":"Hartigan","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William S.","family":"Weintraub","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel S.","family":"Berman","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Koon K.","family":"Teo","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leslee J.","family":"Shaw","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven P.","family":"Sedlis","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Merril","family":"Knudtson","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mihaela","family":"Aslan","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcin","family":"Dada","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William E.","family":"Boden","sequence":"additional","affiliation":[{"name":"From the Department of Cardiovascular Research, Saint Luke\u2019s Mid America Heart Institute, University of Missouri-Kansas City (J.A.S., D.J.C.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Christiana Care Health System, Newark, DE (P.K., W.S.W.); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT (P.H., M.A.,); Cedars-Sinai Medical Center, Los Angeles, CA (D.S.B.); McMaster University Medical Center, Hamilton, Ontario, Canada (K.K.T.); Emory..."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G. 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