Yet another article compares Medical therapy with PCI (Stenting) in patients with stable Coronary Artery Disease. This time the focus was on control of angina symptoms, rather than survival. However, its conclusions were similar in that in this group of stable patients, medical therapy alone has become just as effective as PCI (75% vs. 77% control of symptoms).
What surprised to me is that in the studies reviewed here, these results were observed with relative simple medications and without additional behavior modifications such as exercise, weight loss and cessation of smoking. In addition, while this type of therapy has been around for a long time, PCI as an intervention has continued to evolve (although the new drug eluting stents were not included in this review).
Since PCI for stable CAD does not prolong life, protect against progression of disease or future heart attacks, the only benefit is temporary relief of angina.
It is therefore reasonable to conclude that a combination of Optimal Medical Therapy (which includes also behavior modifications) will benefit a stable patient more than PCI.
If added to the potential complications, a recurrence rates of 50% and costs of PCI, as well as the risks associated with anti-platelet therapy and non-cardiac surgery, it is hard to justify stenting in these patients.
I realize that this yet another blog about the the excessive and occasional inappropriate use of PCI in the treatment of Coronary Artery Disease, but this the direct result of a therapy that is not being adjusted despite overwhelming evidence to do so.
Practioners usually know long in advance what works – long before reviews such as this one become available. I certainly did!
Wijeysundera HC et al. Meta-analysis: Effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med 2010 Mar 16; 152:370