While it is widely known from literature that PCI is beneficial in reducing mortality and MI in patients with acute coronary syndrome, the role of PCI in treating stable coronary artery disease (CAD) remains controversial. A new meta-analysis has found that PCI for stable CAD patients had no benefit compared with initial medical therapy. Three researchers discuss the implications of that and other analyses.
In the research published Feb. 28 in Archives of Internal Medicine, Kathleen Stergiopoulos, MD, PhD, and David L. Brown, MD, both of the Stony Brook University Medical Center in Stony Brook, N.Y., performed a meta-analysis that included eight clinical trials from the MEDLINE database between 1970 to September 2011. Their goal was to elucidate conflicting results from the literature regarding the best treatment options for stable coronary artery disease patients—PCI or optimal medical therapy (OMT)?
During the analysis, the researchers examined outcomes of death, nonfatal MI, unplanned revascularization and persistent angina.
What is new?
Brown said that the current analysis excluded study data that may be outdated such as those including balloon angioplasty or those where medical therapies did not reflect current clinical practice interventions.
A total of 7,229 patients were included in the analysis. The reported event rates for death with PCI and OMT were 8.9 percent vs. 9.1 percent, respectively. For nonfatal MI and unplanned revascularization, the rates were 21.4 percent vs. 30.7 percent and 29 percent vs. 33 percent for PCI and OMT, respectively.
“We found that compared to medical therapy, stenting did not reduce the risk of death, the risk of heart attack, the need for subsequent procedures or angina symptoms in the stable patient population,” Brown told Cardiovascular Business.
Brown added that the results should come as no surprise as they confirm what has been previously written in the guidelines: patients with stable symptoms should be first treated with OMT and referred for stenting only when symptoms remain unacceptable.
“This has been recommended before and is what the guidelines say but it has been shown that interventional cardiologists are not following this,” Brown said. “More than half of patients who receive stents for stable symptoms are not on optimal medical therapy, meaning that there is still a disconnect between the data, the guidelines and goings-on in clinical practice.”
“What more will it take to turn the tide of treatment?” asked William E. Boden, MD, chief of medicine at the Samuel S. Stratton VA Medical Center in Albany, N.Y., in an accompanying editorial.
“This is the big battle that has been raging since the COURAGE trial in 2007,” Boden said in an interview. Boden added that COURAGE was the first randomized study to show that there was no incremental benefit of PCI on top of OMT when compared with OMT alone (New Engl J Med 2007;356:1503-1316).
“This was not a very popular trial in the interventional community and they rose up in unison to attack its credibility,” he said. “The results were very much a surprise to many people—PCI would not be superior to OMT in this patient population and not be superior to OMT during long-term follow-up.”
Likewise two other trials—BARI 2D and the STICH trial—showed similar results. In BARI 2D, (led by Boden) results showed that in type 2 diabetic and heart failure patients randomized to receive PCI or CABG plus OMT or OMT alone, there was no difference in mortality between the two revascularization procedures and OMT (N Engl J Med 2009;260:2503-2515).
Boden said the current meta-analysis is more of an “apples to apples comparison” of contemporary treatments, which builds on the “mounting evidence that has shown that there is no incremental clinical benefit of PCI as compared with OMT in patients with stable angina and chronic coronary disease.”
Despite being well known and widespread, “this is an important message that continues not to be embraced by either the practice community or the lay public,” Boden said. “It continues to be the more dominate perception that despite the lack of evidence, PCI is still favored over OMT and people continue to push PCI rather than medical therapy.
“We continue to turn a blind eye on medical therapy and continue to under-treat patients who really should be treated with OMT,” Boden said.
Stergiopoulos and Brown found that only 44 percent of patients are treated with OMT prior to PCI.