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Invasive vs. Medical Treatment for Chronic Symptomatic Coronary Disease

Among elders with angina, quality-of-life measures and mortality rates were similar at 1 year, regardless of therapy.

Is an early invasive strategy, including angiography and revascularization when appropriate, superior to medical management in elderly patients with chronic angina? Swiss researchers conducted a 1-year trial that involved 301 patients (age, 75 or older) with chronic symptomatic coronary disease despite at least 2 antianginal medications; patients were randomized to either invasive or optimal medical management. Primary endpoints were quality of life and freedom from major adverse clinical events (MACE: death, nonfatal myocardial infarction, acute coronary syndrome, or hospitalization for uncontrolled symptoms).

Six-month results showed beneficial effects on quality of life after invasive management, but with some excess mortality. One-year results showed no significant difference in rates of mortality (11% for invasive, 8% for medical) or of death or nonfatal MI (17% for invasive, 20% for medical). At 1 year, MACE was significantly more common in patients who underwent medical therapy (64% vs. 25% for invasive); quality-of-life measures were not significantly different. Of note, 46% of patients in the medical-management group ultimately underwent revascularization, compared with 65% of the invasive-management group.

Comment: These results suggest that quality-of-life measures are similar at 1 year in elders who undergo invasive or medical management for chronic symptomatic coronary disease. However, the rate of MACE was higher in the medical-management group, driven mostly by hospitalizations for acute coronary syndromes or symptoms. The high number of crossovers during follow-up makes interpretation difficult: The similarity in quality of life at 1 year might be due, in part, to late revascularization in the medical-management group. Rates of "hard" endpoints were similar, although the study was not powered to detect small differences. The authors conclude that elders with chronic angina have a choice -- an early invasive strategy with its attendant risks or aggressive medical therapy with significant risk for later hospitalizations and revascularization.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine April 15, 2003

Citation(s):

Pfisterer M et al. Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive vs optimized medical treatment strategy: One-year results of the randomized TIME trial. JAMA 2003 Mar 5; 289:1117-23.

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