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Percutaneous coronary intervention versus medical therapy in stable coronary artery disease: the unresolved conundrum. [Review]

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Citation: Jacc: Cardiovascular Interventions. 6(10):993-8, 2013 Oct.PMID: 24156960Institution: MedStar Health Research Institute | MedStar Heart & Vascular InstituteForm of publication: Journal ArticleMedline article type(s): Journal Article | Research Support, Non-U.S. Gov't | ReviewSubject headings: *Cardiovascular Agents/tu [Therapeutic Use] | *Coronary Artery Disease/th [Therapy] | *Percutaneous Coronary Intervention | Cardiovascular Agents/ae [Adverse Effects] | Coronary Artery Disease/co [Complications] | Coronary Artery Disease/di [Diagnosis] | Coronary Artery Disease/dt [Drug Therapy] | Coronary Artery Disease/mo [Mortality] | Evidence-Based Medicine | Humans | Myocardial Infarction/et [Etiology] | Patient Selection | Percutaneous Coronary Intervention/ae [Adverse Effects] | Percutaneous Coronary Intervention/mo [Mortality] | Risk Assessment | Risk Factors | Severity of Illness Index | Therapeutic Equipoise | Time Factors | Treatment OutcomeLocal holdings: Available online through MWHC library: 2008 - presentISSN:

1876-7605

Name of journal: JACC. Cardiovascular interventionsAbstract: One of the major dilemmas facing physicians is what diagnostic and therapeutic approaches should be recommended to those stable coronary artery disease patients whose symptoms are adequately controlled on medical therapy. This study sought to assess the evidence-based data relating to whether: 1) all patients with significant coronary lesions (i.e., ischemia-producing) should undergo percutaneous coronary intervention (PCI); 2) the best therapeutic approach is optimal medical therapy; or 3) PCI should be performed, but only in certain subsets of patients. We reviewed all recent meta-analyses of prospective randomized trials that compared the outcomes of medical therapy and PCI in stable, symptomatically controlled, coronary artery disease patients. To provide greater insights to the clinician, we then analyzed, in depth, 3 comprehensive and widely quoted randomized trials. Review of recently published (2012) meta-analyses, and the detailed analyses of 3 widely quoted individual studies, indicate no difference exists between PCI and medical therapy in nonfatal MI or in all-cause or cardiovascular mortality. Thus, clinical equipoise exists: in other words, there is no evidence-based justification for adopting 1 therapeutic strategy over the other. Therefore, it is not inappropriate, until additional evidence emerges, for the responsible, experienced physician to weigh several sources of information in formulating a recommendation to the patient, even though definitive evidence-based data are not as yet available. Such sources may include assessment of the individual patient's clinical presentation, assessment of the severity of ischemia, and the patient's precise coronary anatomy. Critical for more-reliable decision making will be future development of accurate measures of the individual patient's risk of MI and/or death, whether by biomarker, imaging, or ischemia assessments. Copyright 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.All authors: Epstein SE, Kent KM, Panza JA, Pichard AD, Waksman RDigital Object Identifier:

http://dx.doi.org/10.1016/j.jcin.2013.07.003

Date added to catalog: 2014-08-21

Holdings ( 1 )
Title notes ( 3 )

Holdings
Item type	Current library	Collection	Call number	Status	Date due	Barcode
Journal Article	MedStar Authors Catalog	Article		Available		24156960

Available online through MWHC library: 2008 - present

One of the major dilemmas facing physicians is what diagnostic and therapeutic approaches should be recommended to those stable coronary artery disease patients whose symptoms are adequately controlled on medical therapy. This study sought to assess the evidence-based data relating to whether: 1) all patients with significant coronary lesions (i.e., ischemia-producing) should undergo percutaneous coronary intervention (PCI); 2) the best therapeutic approach is optimal medical therapy; or 3) PCI should be performed, but only in certain subsets of patients. We reviewed all recent meta-analyses of prospective randomized trials that compared the outcomes of medical therapy and PCI in stable, symptomatically controlled, coronary artery disease patients. To provide greater insights to the clinician, we then analyzed, in depth, 3 comprehensive and widely quoted randomized trials. Review of recently published (2012) meta-analyses, and the detailed analyses of 3 widely quoted individual studies, indicate no difference exists between PCI and medical therapy in nonfatal MI or in all-cause or cardiovascular mortality. Thus, clinical equipoise exists: in other words, there is no evidence-based justification for adopting 1 therapeutic strategy over the other. Therefore, it is not inappropriate, until additional evidence emerges, for the responsible, experienced physician to weigh several sources of information in formulating a recommendation to the patient, even though definitive evidence-based data are not as yet available. Such sources may include assessment of the individual patient's clinical presentation, assessment of the severity of ischemia, and the patient's precise coronary anatomy. Critical for more-reliable decision making will be future development of accurate measures of the individual patient's risk of MI and/or death, whether by biomarker, imaging, or ischemia assessments. Copyright 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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