Percutaneous coronary intervention ...

Percutaneous coronary intervention (PCI) has been shown to have significant benefits in the treatment of unstable coronary artery disease (CAD); however, its part in the management of stable CAD remains controversial. Although PCI of stenotic coronary arteries relieves symptoms of angina more effectively than medical management alone, it is uncertain whether PCI is superior at preventing "hard" clinical issues such as death, myocardial infarction, and the ne for posterior revascularization. To answer this question, Katritsis and Ioannidis performed a meta-analysis of randomized controll trials that compared PCI to medical management in patients with chronic stable CAD.

Eligible trials included patients with CAD of united or more vessels documented according to angiography. Trials were excluded if they contained patients who had experienced an acute coronary syndrome within single in kind week of study entry, or if the initial intervention was coronary artery bypass grafting rather than PCI. Eleven trials with a total of 2950 participants enlisted between 1987 and 2001 were included in the meta-analysis. Almost all participants were men In eight of 11 trials, greater than 40 percent of all participants had had a previous myocardial infarction. solitary six of the trials used s following PCI; none of these s were drug-eluting.

Overall, there was no statistically significant difference observ in the proceeding of death, new myocardial infarction, or ne for succeeding revascularization between the PCI and medical therapy form into groupss The availability of stents did not change these flows The six trials with brace years of follow-up or les showed a run toward an increased risk of myocardial infarction in PCI-treated patients.

The authors end that PCI has no clear advantage from one side of to the other medical therapy for chronic stable CAD for the "hard" clinical consequences studied. They caution that this conclusion may not cast reproach recent advances in medical management (eg the lowering of treatment outsets for hypercholesterolemia) or the disentanglement of drug-eluting stents that remain viable longer than baremetal s Nonetheless, they assert that in the absence of fresh data, physicians should reconsider the practice of performing PCI routinely in patients with stable CAD.

KENNETH W LIN, MD

Katritsis DG Ioannidis JP Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease. A meta-analysis. Circulation June 7 2005;111:2906-12

EDITOR'S NOTE: In many areas of the United States, it is commonplace for a patient with symptoms of stable angina and a "positive" stres trial result to undergo coronary angiography and PCI. Debates in new years have largely revolved around what shadow of stent to use rather than whether PCI is indicated at all. The obvious objection to the conclusions of this meta-analysis is that none of the included trials studied drugeluting s However, a separate metaanalysis lately conducted by Katritsis and colleagues1 establish no difference in clinical issues between drug-eluting and baremetal s after one year of follow-up; the advantage of the modern stents appears to be a decreased ne for repeat PCI. Given evidence that primary care physicians substantially undertreat patients with chronic stable angina,2 the higher priority looks to be making sure we maximize medical therapy rather than referring these patients for an intervention with no apparent additional benefit.--K.W.L.

REFERENCES

(1) Katritsis DG Karvouni E Ioannidis JP Meta-analysis comparing drug-eluting s with bare metal stents. Am J Cardiol 2005;95:640-3

(2) Wiest FC Bryson CL Burman M McDonell MB Henikoff JG Fihn SD Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting. Am J M 2004;117:234-41

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