Patients with chronic angina caused by stable CAD do just as well—if not better—with intensive medical therapy as with balloon angioplasty and stenting, according to a major study at 50 U.S. and Canadian centers.
Doctors randomized 2,287 patients with myocardial ischemia and significant CAD to receive either percutaneous coronary intervention (PCI) or drug therapy. All the PCI patients achieved normal coronary artery flow (<20% stenosis); none required emergency intervention; most of the stents involved were of the bare-metal variety since drug-eluting stents were not available until the final six months of the study.
Medical supervision comprised antiplatelet therapy with either aspirin or clopidrogel plus the following either alone or in combination: a cardioselective beta blocker, a noncardioselective beta blocker, a calcium-channel blocker, a nitrate, and an angiotensin II receptor blocker. Medical therapy also included aggressive statin use designed to reach an LDL target level of 60-85 mg/dL. After this target was achieved, HDL levels were raised and triglyceride levels lowered with exercise, extended-release niacin, and fibrates, alone or in combination.
During a median follow-up of 4.6 years (range 2.5-7 years), the medical group suffered fewer strokes, MIs, hospitalizations for acute coronary syndrome, or death than did the PCI group, but the differences between the two groups did not reach statistical significance. Angina relief was higher in the PCI group at one year (66% vs. 58% were pain free), but by year five the difference was minor—74% of the stented group and 72% of the medical group reported no angina.
“Our findings reinforce guidelines that state PCI can be safely deferred in patients with stable CAD, even in those with extensive, multivessel involvement and inducible ischemia, provided that intensive, multifaceted medical therapy is maintained,” the researchers concluded (N Engl J Med. 2007;356:1503-1516).
In an accompanying editorial Judith S. Hochman, MD, director of cardiovascular research at New York University School of Medicine, said the findings “should lead to changes in treating stable CAD, with expected substantial savings.” PCI, she added, “should not play a major role [in managing CAD patients] as part of a secondary prevention strategy.”