Cardiologists claim PCIs may not be appropriate to treat stable ischemic heart disease

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 - Tim Casey
Tim Casey, Executive Editor

Physicians in the U.S. perform approximately 500,000 PCIs each year. At a cost of more than $15,000 per procedure, PCIs account for approximately $7.5 billion in annual healthcare spending. And that estimate may be low, according to William S. Weintraub, MD, and William E. Boden, MD.

The cardiologists published a review of PCIs online in JAMA Internal Medicine on July 5 and argued that PCIs may not be best to treat patients with stable ischemic heart disease.

“With uncertain benefits and high costs, [PCI] can only be a low-value intervention at best, and a waste of money at worst,” they wrote.

Weintraub and Boden cited the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, which randomized 2,287 patients with stable ischemic heart disease to receive PCI with medical therapy or medical therapy alone. After a median of 4.6 years, the groups had similar rates of all-cause mortality and nonfatal MI. Patients undergoing PCI had a modest improvement in their quality of life, but Weintraub and Boden mentioned that the improvement did not persist past three years.

Other studies found that PCI did not significantly improve outcomes, according to Weintraub and Boden. For instance, the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) study randomized 2,368 patients with type 2 diabetes and obstructive coronary artery disease to revascularization with intensive medical therapy or intensive medical therapy alone. After five years, patients who underwent PCI had similar rates of survival and freedom from death, MI or stroke compared with patients who only received medical therapy.

“We need to come to terms with the realization that we do not have adequate scientific information for informed clinical decision making regarding PCI for stable ischemic heart disease,” they wrote.

They noted that medical societies and policy makers must determine whether PCI should continued to be used as an initial management strategy in patients with stable ischemic heart disease. They added that costs and value must be taken into consideration, too. If it were up to Weintraub and Boden, they would change current practice.

“Until such definitive scientific evidence becomes widely available, patients, clinicians, payers, and health policy makers would be best served by adhering to the present body of evidence, namely, that for the majority of patients with stable ischemic heart disease, a ‘medical therapy first’ approach to treatment, consistent with existing professional society guidelines, should be embraced,” they wrote. ”Revascularization should be reserved for only those patients who experience treatment failure after an adequate trial of medical therapy, whose anginal symptoms or quality of life deteriorate, or who have large areas of myocardium at risk demonstrated at low workload.”