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Percutaneous Coronary Intervention for Stable Coronary Artery Disease: The Debate Continues

Percutaneous Coronary Intervention for Stable Coronary Artery Disease: The Debate Continues We read the recent meta-analysis by Drs Stergiopoulos and Brown1 comparing initial medical therapy with initial stent implantation for stable coronary artery disease (CAD) as well as the accompanying Invited Commentary by Dr Boden2 with great interest. However, we are concerned that the choice of trials does not support the conclusions arrived at. We agree with Dr Boden that any meta-analysis comparing optimal medical therapy (OMT) alone with OMT and percutaneous coronary intervention (PCI) in patients with stable CAD that fails to exclude both acute and post–myocardial infarction (MI) trials suffers from a significant methodological flaw. Application of this criteria to the current meta-analysis reveals that the trials included represent a heterogeneous population, particularly the Open Artery Trial (TOAT), Desobstruction Coronaire en Post-Infarctus (DECOPI) trial, and Occluded Artery Trial (OAT), which together account for a third of the patients (2333 of a total 7229 patients) included in this meta-analysis. The largest of these, the OAT (N = 2166), was clearly a trial of stable but high-risk patients, ie, depressed ejection fraction or proximal occlusion of a major epicardial vessel, following completed infarcts with total occlusion of the infarct-related vessel. Enrollment in this trial did not require demonstration of ischemia or symptoms. In fact, patients with clinically significant ischemia or angina at rest were excluded.3 Likewise, the DECOPI trial (N = 212) was a trial of patients with recent completed infarcts with an occluded infarct-related artery and excluded patients with spontaneous or low-level ischemia.4 Similarly the TOAT Study (N = 66 patients) included patients with an occluded left anterior descending artery following a recent MI and no evidence of ischemia on a modified Bruce treadmill exercise test.5 The OAT and DECOPI trial are the basis for the current practice of not intervening on an occluded artery 3 to 28 days after MI in stable patients. These patients with a recent infarct, an occluded vessel, and no clinically significant ischemia are very different from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) population with obstructive CAD and chronic stable angina or demonstrable ischemia.6 The co-mingling of these populations prevents us from drawing any meaningful conclusions. The complexity of the spectrum of stable CAD and the failure of a one-size-fits-all approach is clear in the appropriateness criteria for revascularization in stable CAD put forth by the American College of Cardiology. Hopefully the publication of the recently halted FAME II trial (Fractional Flow Reserve–Guided Percutaneous Coronary Intervention Plus Optimal Medical Treatment vs Optimal Medical Treatment Alone in Patients With Stable Coronary Artery Disease), using fractional flow reserve–guided lesion assessment and then randomization to PCI + OMT vs OMT alone, will enlighten and better inform our decision making in stable CAD. Back to top Article Information Correspondence: Dr Peter, Division of Cardiology, Department of Medicine, Louisiana State University at Shreveport, 1501 Kings Hwy, Shreveport, LA 71130 (elvpeter@yahoo.com). Financial Disclosure: None reported. References 1. Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172(4):312-31922371919PubMedGoogle ScholarCrossref 2. Boden WE. Mounting evidence for lack of PCI benefit in stable ischemic heart disease: what more will it take to turn the tide of treatment? Arch Intern Med. 2012;172(4):319-32122371920PubMedGoogle ScholarCrossref 3. Hochman JS, Lamas GA, Buller CE, et al; Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006;355(23):2395-240717105759PubMedGoogle ScholarCrossref 4. Steg PG, Thuaire C, Himbert D, et al; DECOPI Investigators. DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction. Eur Heart J. 2004;25(24):2187-219415589635PubMedGoogle ScholarCrossref 5. Yousef ZR, Redwood SR, Bucknall CA, Sulke AN, Marber MS. Late intervention after anterior myocardial infarction: effects on left ventricular size, function, quality of life, and exercise tolerance: results of the Open Artery Trial (TOAT Study). J Am Coll Cardiol. 2002;40(5):869-87612225709PubMedGoogle ScholarCrossref 6. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-151617387127PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Percutaneous Coronary Intervention for Stable Coronary Artery Disease: The Debate Continues

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1753
Publisher site
See Article on Publisher Site

Abstract

We read the recent meta-analysis by Drs Stergiopoulos and Brown1 comparing initial medical therapy with initial stent implantation for stable coronary artery disease (CAD) as well as the accompanying Invited Commentary by Dr Boden2 with great interest. However, we are concerned that the choice of trials does not support the conclusions arrived at. We agree with Dr Boden that any meta-analysis comparing optimal medical therapy (OMT) alone with OMT and percutaneous coronary intervention (PCI) in patients with stable CAD that fails to exclude both acute and post–myocardial infarction (MI) trials suffers from a significant methodological flaw. Application of this criteria to the current meta-analysis reveals that the trials included represent a heterogeneous population, particularly the Open Artery Trial (TOAT), Desobstruction Coronaire en Post-Infarctus (DECOPI) trial, and Occluded Artery Trial (OAT), which together account for a third of the patients (2333 of a total 7229 patients) included in this meta-analysis. The largest of these, the OAT (N = 2166), was clearly a trial of stable but high-risk patients, ie, depressed ejection fraction or proximal occlusion of a major epicardial vessel, following completed infarcts with total occlusion of the infarct-related vessel. Enrollment in this trial did not require demonstration of ischemia or symptoms. In fact, patients with clinically significant ischemia or angina at rest were excluded.3 Likewise, the DECOPI trial (N = 212) was a trial of patients with recent completed infarcts with an occluded infarct-related artery and excluded patients with spontaneous or low-level ischemia.4 Similarly the TOAT Study (N = 66 patients) included patients with an occluded left anterior descending artery following a recent MI and no evidence of ischemia on a modified Bruce treadmill exercise test.5 The OAT and DECOPI trial are the basis for the current practice of not intervening on an occluded artery 3 to 28 days after MI in stable patients. These patients with a recent infarct, an occluded vessel, and no clinically significant ischemia are very different from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) population with obstructive CAD and chronic stable angina or demonstrable ischemia.6 The co-mingling of these populations prevents us from drawing any meaningful conclusions. The complexity of the spectrum of stable CAD and the failure of a one-size-fits-all approach is clear in the appropriateness criteria for revascularization in stable CAD put forth by the American College of Cardiology. Hopefully the publication of the recently halted FAME II trial (Fractional Flow Reserve–Guided Percutaneous Coronary Intervention Plus Optimal Medical Treatment vs Optimal Medical Treatment Alone in Patients With Stable Coronary Artery Disease), using fractional flow reserve–guided lesion assessment and then randomization to PCI + OMT vs OMT alone, will enlighten and better inform our decision making in stable CAD. Back to top Article Information Correspondence: Dr Peter, Division of Cardiology, Department of Medicine, Louisiana State University at Shreveport, 1501 Kings Hwy, Shreveport, LA 71130 (elvpeter@yahoo.com). Financial Disclosure: None reported. References 1. Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172(4):312-31922371919PubMedGoogle ScholarCrossref 2. Boden WE. Mounting evidence for lack of PCI benefit in stable ischemic heart disease: what more will it take to turn the tide of treatment? Arch Intern Med. 2012;172(4):319-32122371920PubMedGoogle ScholarCrossref 3. Hochman JS, Lamas GA, Buller CE, et al; Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006;355(23):2395-240717105759PubMedGoogle ScholarCrossref 4. Steg PG, Thuaire C, Himbert D, et al; DECOPI Investigators. DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction. Eur Heart J. 2004;25(24):2187-219415589635PubMedGoogle ScholarCrossref 5. Yousef ZR, Redwood SR, Bucknall CA, Sulke AN, Marber MS. Late intervention after anterior myocardial infarction: effects on left ventricular size, function, quality of life, and exercise tolerance: results of the Open Artery Trial (TOAT Study). J Am Coll Cardiol. 2002;40(5):869-87612225709PubMedGoogle ScholarCrossref 6. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-151617387127PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 9, 2012

Keywords: percutaneous coronary intervention,coronary arteriosclerosis

References