Meta-analysis: PCI Beats Medical Therapy for Angina Relief but Little Else in Stable CAD

Download this article's Factoid in PDF (& PPT for Gold Subscribers)

Percutaneous coronary intervention (PCI) provides no benefits with regard to mortality, myocardial infarction (MI), or repeat revascularization compared with optimal medical therapy in patients with stable coronary artery disease (CAD), but it does achieve better angina relief. Results of a meta-analysis were published online August 7, 2012, ahead of print in Circulation: Cardiovascular Interventions.

Researchers led by Sripal Bangalore, MD, MHA, of the New York University School of Medicine (New York, NY), pooled results from 7,182 patients with stable CAD enrolled in 12 randomized trials that compared PCI and medical therapy. Baseline characteristics were similar between the PCI and medical therapy groups, with subjects consisting mainly of middle-aged men. Angioplasty without stenting was performed in the majority of trials, with only a few (BARI 2D, COURAGE, MASS-2, and JSAP) including stents; only a small fraction of patients in these trials received DES.

Overall, there was no difference in outcomes between the PCI and medical therapy groups, with the exception of freedom from angina, which was greater with PCI (table 1).

Table 1. Outcomes, PCI vs. Optimal Medical Therapy

All-cause mortality did show a trend favoring PCI, especially in trials with 5 years or longer follow-up (RR 0.82; 95% CI 0.65-1.02). The same was true for CV death (RR 0.70; 95% CI 0.46-1.08). Results for the other endpoints were maintained at all time points. Removal of the lone industry-sponsored trial (AVERT) and another which did not report sponsorship (DEFER) made no difference in overall mortality. Likewise, mortality results remained unchanged when only the trials featuring more than 50% stent use in the PCI arm were analyzed.

The study authors note that while the absence of newer-generation DES in the studies makes it difficult to extrapolate the results to current practice, medical therapies have advanced as well “with usage of high-dose statins and antiplatelet therapy as standard of care.” Medical therapy in the included studies varied widely, with nearly all participants taking at least daily aspirin and most on antianginal therapy with nitrates and beta-blockers. Statin use also varied. The studies enrolled patients as early as 1987 and as late as 2005.

“In this most rigorous and comprehensive analysis in patients with stable [CAD], PCI, as compared with [optimal medical therapy], did not reduce the risk of mortality, cardiovascular death, nonfatal [MI], or revascularization,” the authors conclude. “PCI, however, provided greater angina relief . . . [and] appeared to show a benefit for all-cause mortality and cardiac death that was attenuated when recent studies (with more aggressive medical therapy) with a high proportion of stent use were analyzed.”

Like COURAGE, but a Bit More Positive

According to Manesh R. Patel, MD, of the Duke Clinical Research Institute (Durham, NC), the meta-analysis validates existing knowledge and recommendations. “These findings confirm our understanding that PCI for stable angina improves symptoms, a finding that is important for caring for our patients,” he told TCTMD in an e-mail communication.

He noted that the results echo those of the COURAGE trial, which found no benefit in hard outcomes with PCI compared with medical therapy alone in stable CAD patients, although the current analysis is perhaps “a bit more positive” with the trends favoring PCI for mortality and CV mortality.

In addition, the influence of modern-day DES should only improve results by “reducing repeat procedures and improving long-term patency,” Dr. Patel said.

He added that current methods of measuring functional ischemia represent another advancement since the time of the studies in the meta-analysis. “There is good understanding now in cardiology that ischemia-driven revascularization (especially very specific detection with FFR) affords the best outcomes,” Dr. Patel said. “So yes, it makes sense that studies with higher rates of patients with ischemia or the patients with demonstrable ischemia do better with PCI.”

Overall, he observed, studies such as those included in the meta-analysis like COURAGE have had an effect on rates of PCI in stable CAD patients. “These types of studies have solidified our understanding of coronary revascularization,” Dr. Patel said. “With improved techniques, better medical therapy, and DES, the rates of PCI have decreased.”

---

Source:
Pursnani S, Korley F, Gopaul R, et al. Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: A systematic review and meta-analysis of randomized clinical trials. Circ Cardiovasc Interv. 2012:Epub ahead of print.

Related Stories:

• NY Registry Shows Improved Outcomes with PCI vs. Medical Therapy in Stable Patients
• Meta-Analysis Questions Appropriateness of PCI in Stable CAD 
• The COURAGE Effect: Sustained Decline Seen in PCI for Stable Angina