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More Data on Medical Therapy vs. PCI in Patients with Stable Angina

Both medical therapy and PCI have a place in the management of patients with stable angina.

The COURAGE trial generated much discussion in 2007, when its investigators presented results suggesting that, in patients with stable angina — but without high-risk disease identified by angiograms — percutaneous coronary intervention (PCI) did not lower rates of myocardial infarction or death compared with best medical therapy. In 2008, the COURAGE investigators presented data on additional important outcomes — symptom relief and quality of life (QOL).

Among 2287 patients who were randomized to PCI plus optimal medical therapy or optimal medical therapy alone, the proportion of patients who were free of angina at 3-month follow-up was significantly higher in the PCI group (53% vs. 42%), and the PCI group also had generally better angina-specific QOL scores. Generally, this advantage persisted from 6 to 24 months depending on the measure. Patients with more-severe angina benefited more from PCI. By 36 months, health status and QOL did not differ significantly between the groups (JW Aug 13 2008).

In another study, about selection of patients for PCI, investigators used Medicare data to determine how often patients who underwent elective PCI for stable coronary artery disease had undergone stress testing in the 90 days prior to their procedures, as current guidelines often call for documenting ischemia prior to elective PCI. Less than half the sample (44.5%) had undergone stress testing, and geographic variation in rates of stress testing before PCI was wide (22% to 71%). Lower rates were seen in women, older patients (85), and those with prior heart failure or catheterization. Patients treated by higher-volume interventionalists were less likely to have undergone stress testing prior to PCI (JW Oct 28 2008).

What do these data tell us? In my opinion, both medical therapy and PCI have a place in management of patients with stable angina. Those who support intervention will rightly point out that prospectively evaluated participants in COURAGE underwent angiography to define their coronary artery disease and that those with left-main disease, 3-vessel disease with depressed ejection fraction, or disease unsuitable for PCI revascularization were excluded from randomization. But the data suggest that most patients can be managed successfully with medical therapy when high-risk features (e.g., significantly depressed left ventricular function, difficult-to-control heart failure, markedly positive stress test) are absent, and PCI can be reserved for those who do not respond symptomatically to optimal medical therapy. The Medicare study demonstrates the wide variation in practice for stress testing before elective PCI, but, unfortunately, these researchers could not look at linked outcomes data to tell us whether preprocedural stress testing was associated with better outcomes after PCI.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine December 29, 2008