Medical vs. Invasive Approaches in Patients with Stable Angina

Medical vs. Invasive Approaches in Patients with Stable Angina

Although patients benefited similarly from both approaches in a randomized trial, cardiologists believe that PCI is better.

Early invasive strategies, which include angiography, are associated with favorable outcomes in patients with acute coronary syndromes such as myocardial infarction or unstable angina. But do these benefits carry over to patients with stable angina? In 2007, the widely publicized COURAGE trial provided some answers. In this trial, 2287 patients (mean age, 62) were randomized to percutaneous coronary intervention (PCI) plus optimal medical therapy or to optimal medical therapy alone. Subjects had either $≥$ 70% stenosis identified by angiography with objective evidence of ischemia or classic angina with $≥$ 80% stenosis. High-risk patients, such as those with class IV angina, substantially reduced left ventricular ejection fractions (<30%), or markedly positive stress tests, were excluded (Journal Watch Mar 29 2007).

In the PCI group, 94% received stents (97% were bare metal). Adherence to optimal medical therapy was excellent in both groups. During a median follow-up of 4.6 years, the incidence of the primary outcome — death or MI — was similar in the two groups (about 19%); hospitalization and stroke rates were also similar in the two groups. However, the PCI group had a significantly lower rate of revascularization during follow-up (21% vs. 33%) and better angina-free survival at 1 year (66% vs. 58%) and 3 years (72% vs.67%) although not at 5 years (74% vs. 72%).

What do cardiologists think about PCI versus medical management in patients with stable angina? Investigators conducted focus groups, consisting of 20 cardiologists, to elicit their opinions on this question. During these interviews, conducted in 2006, researchers described hypothetical case scenarios. Despite acknowledging a lack of proof that PCI lengthens survival or lowers MI rates, these cardiologists expressed belief that PCI benefited stable-angina patients. Rationales included better treatment of ischemia, belief that an "open artery" was beneficial, potential regret if patients suffered cardiac events after receiving only medication, medicolegal concerns, and improvements in patients’ wellbeing and anxiety levels (Journal Watch Cardiology Sep 12 2007).

The COURAGE trial suggests that, in patients with stable angina, an initial invasive approach is associated with somewhat better early control of symptoms but with mortality and infarction rates that are similar to those seen with medical therapy. Critics point out that <10% of screened patients were eligible for enrollment, which raises questions about the generalizability of the findings. Although these data support current guidelines that allow for deferring angiography in selected patients with stable angina, they should not be extended to higher-risk patients, such as those who present with acute coronary syndromes. The data from the focus groups suggest that difficulties will arise in preventing the "oculostenotic reflex" of performing PCI on anatomically significant lesions once the decision to pursue angiography is made.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine December 28, 2007