In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug 
Evaluation (COURAGE) study, a revascularization strategy trial with optimal 
medical therapy in both arms, the low-density lipoprotein (LDL) cholesterol goal 
was 60 to 85 mg/dl; this was revised to <70 mg/dl in 2004. COURAGE patients (n = 
2,287) were titrated with increasing statin doses to achieve the initial LDL 
cholesterol goal using a prespecified protocol. Ezetimibe was not available when 
study enrollment began in 1999 but became available after approval in 2003. 
After maximizing statin dose, ezetimibe was added to reach the LDL cholesterol 
goal in 34% of patients (n = 734). Median baseline LDL cholesterol was higher in 
patients who received ezetimibe than in those who did not (109 vs 96 mg/dl). At 
baseline, 18% of patients who would later receive ezetimibe had LDL cholesterol 
<85 mg/dl, and 8% had LDL cholesterol <70 mg/dl. On maximum tolerated statin 
(with or without other lipid-lowering drugs), 40% had LDL cholesterol <85 mg/dl 
and 23% had LDL cholesterol <70 mg/dl before starting ezetimibe. At the final 
study visit, 68% of ezetimibe patients achieved LDL cholesterol <85 mg/dl, and 
46% achieved LDL cholesterol <70 mg/dl. Using Cox regression analysis, the most 
significant factors associated with achieving LDL cholesterol goals were lower 
baseline LDL cholesterol, average statin dose, and ezetimibe use. In conclusion, 
after maximizing statin dose, the addition of ezetimibe results in a substantial 
increase in the percentage of patients who reach LDL cholesterol goal, a key 
component of optimal medical therapy.