Review challenges benefit of PCI plus medical therapy

A combination of PCI and medical therapy did not lead to better outcomes in patients with stable coronary artery disease and MI compared with medical therapy alone, a review published online Dec. 2 in JAMA Internal Medicine found.

Researchers led by Kathleen Stergiopoulos, MD, PhD, of the State University of New York-Stony Brook School of Medicine in Stony Brook, analyzed studies between 1970 and 2012 that compared the two therapy approaches and included five in their final review. All five were randomized clinical trials in which more than half of the 5,286 patients were treated with stents and statins. As outcomes, they looked at all-cause mortality, nonfatal MI, unplanned revascularization and angina.

The main finding of their meta-analysis, the authors wrote, was that “a strategy of initial PCI in combination with MT [medical therapy] results in no significant reduction of mortality, nonfatal MI, unplanned revascularization, or angina compared with MT alone.”

Of the 5,286 patients, 4,064 were diagnosed with MI. The mortality rate for PCI with MT was 6.5 percent vs. 7.3 percent in the MT alone group (odds ratio [OR] 0.9). The rates for nonfatal MI were 9.2 percent for PCI with MT and 7.6 percent for MT alone (OR 1.24). For unplanned revascularizations, the rates were 18.3 percent and 28.4 percent (PCI with MT and MT alone, respectively, OR 0.64) and for angina, the rates were 20.3 percent and 23.3 percent, respectively (OR 0.91).

The investigators argued that their findings raise questions about the clinical benefits of revascularization in situations where MI dictates the need for coronary angiography and revascularization. Although this practice of performing PCI based on the presence of ischemia in patients with chest pain or known coronary artery disease is supported by American College of Cardiology Foundation/American Heart Association and European Society of Cardiology guidelines, “there are scant data supporting it,” the authors wrote.