Quality of Life After Percutaneous Coronary Intervention or Medical Therapy for Chronic Total Coronary Occlusions

BACKGROUND: The benefit of percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTOs) to improve clinical symptoms and quality of life (QoL) as compared with optimal medical therapy (OMT) is still under debate because of the scarcity of available randomized trials (RCTs). OBJECTIVES: We evaluated the effect of PCI vs OMT in patients with a CTO and no concomitant coronary lesions in a post-hoc pooled analysis of 2 RCTs. METHODS: A total of 518 patients with a single CTO and no other significant coronary lesion were extracted from 2 RCTs, EUROCTO and DECISION-CTO, which had compared PCI vs OMT. Randomization to PCI or OMT was 1:1 in DECISION and 2:1 in EUROCTO. The clinical status was assessed by the Seattle Angina Questionnaire (SAQ) at baseline and after 12 months, and clinical events were monitored for 3 years. RESULTS: PCI was successful in 92.2%. On an intention-to-treat analysis, PCI appeared to be superior to OMT for the change of angina frequency scores between baseline and follow-up (12.2 vs 8.6; P = 0.009), QoL (19.5 vs 11.3; P < 0.001), and the SAQ summary score (13.8 vs 8.5; P < 0.001). For physical limitation, the difference was just at the level of the Bonferroni correction for multiple tests (P = 0.01). There was a wide variability of changes in SAQ scores. For QoL, the major determinant for a significant improvement was a low baseline score and the assignment to PCI, whereas gender, diabetes, or lesion complexity had no influence. During a mean follow-up of 3.1 years, the clinical endpoints of cardiac death or nonfatal myocardial infarction were similar in both groups (OMT vs PCI: 2.7% vs 5.1%; P = 0.17). The rates of stroke or hospitalization for bleeding were similar, and only target lesion revascularizations were more frequent with OMT (18.8% vs 10.6%; P = 0.005). CONCLUSIONS: In this post-hoc analysis from 2 RCTs of patients with a single CTO and no significant concomitant lesion, PCI achieved better improvement in QoL, angina frequency, and the SAQ summary score than OMT with no signal of excess harm regarding clinical endpoints. (EUROCTO [Evaluate the Utilization of Revascularization or Optimal Medical Therapy for the Treatment of Chronic Total Coronary Occlusions; NCT01760083] and DECISION-CTO [Drug-Eluting Stent Implantation Versus Optimal Medical Treatment in Patients With Chronic Total Occlusion; NCT01078051]).