April 7, 2021European Heart Journal
To stent or not to stent? Treating angina after ISCHEMIA—why a conservative approach with optimal medical therapy is the preferred initial management strategy for chronic coronary syndromes: insights from the ISCHEMIA trial
Key result
Percutaneous coronary intervention added to optimal medical therapy does not convincingly improve mortality or myocardial infarction compared to medical therapy alone in chronic coronary syndromes.
Why the study?
Whether adding PCI to optimal medical therapy improves clinical outcomes in chronic coronary syndromes has been a continuing area of investigation, as trials have not convincingly demonstrated improved hard outcomes.
Does percutaneous coronary intervention added to optimal medical therapy improve clinical outcomes in patients with chronic coronary syndromes?
Key Points
- To evaluate the effectiveness of percutaneous coronary intervention added to optimal medical therapy in chronic coronary syndromes.
- Analyzed data from the ISCHEMIA trial
- Compared outcomes of optimal medical therapy alone versus optimal medical therapy plus PCI
- Focused on angina relief and quality of life measures
- Optimal medical therapy alone effectively relieves angina and manages symptoms without increasing hard outcomes.
Structured PICO
Does percutaneous coronary intervention added to optimal medical therapy improve clinical outcomes in patients with chronic coronary syndromes?
P
Population
Patients with chronic coronary syndromes (CCS)
I
Intervention
Percutaneous coronary intervention (PCI) added to optimal medical therapy (OMT)
C
Comparator
Optimal medical therapy (OMT) alone
O
Outcome
Hard outcomes including all-cause and cardiovascular mortality and myocardial infarction (MI)hard clinical
In patients with chronic coronary syndromes, an initial conservative approach with optimal medical therapy is preferred as PCI has not been shown to improve hard clinical outcomes like mortality or MI.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The probability over 5.7 years that a patient's risk of dying is lower with the invasive strategy is nil, which means: Go with the patient's preference. Not undergoing revascularization is a reasonable strategy because there is no excess mortality.”
“More recently, studies such as COURAGE and BARI 2D have shown no benefit to stenting over medication alone for patients with stable disease, but those trials were criticized for certain design features, such as post-angiogram randomization, inclusion of patients with mild or no ischemia, and the use of older-generation stents. Our goal was to address those concerns and to see what the data revealed.”
“These results indicate that, while stenting may be more effective for symptom control, there's no added risk of major negative outcomes with a conservative approach for patients who meet the criteria included in the study. If patients treated with OMT continue to have angina that is interfering with their lifestyles, they may choose to have an angiogram and, if appropriate, have a stent placed. But it's not a life-or-death decision.”
Implication
Supports OMT-first strategy in chronic coronary syndromes; confirms ISCHEMIA findings but leaves open optimal timing in high-risk subgroups.
Abstract
Whether percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) improves clinical outcomes in patients with chronic coronary syndromes (CCS) has been a continuing area of investigation for more than two decades. While myocardial revascularization, principally with PCI, has been the standard of care for patients with acute coronary syndromes because it improves survival and reduces recurrent myocardial infarction (MI),1,2 its role in patients with CCS is less clear.2,3 Although several randomized clinical trials (RCTs) and meta-analyses indicate that OMT with PCI more effectively relieves angina, decreases the use of anti-anginal medications, and improves functional status and quality of life compared to OMT alone, none of these trials have demonstrated convincingly that an initial strategy of OMT + PCI improves ‘hard’ outcomes, including all-cause and cardiovascular mortality and MI during long-term follow-up.4–12 The recently reported results of the ISCHEMIA trial,13...
Discussion
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Cite This Study
Boden et al. (2021) conducted a review in Chronic coronary syndromes (CCS). Percutaneous coronary intervention (PCI) added to optimal medical therapy (OMT) vs. Optimal medical therapy (OMT) alone was evaluated. Percutaneous coronary intervention added to optimal medical therapy does not convincingly improve mortality or myocardial infarction compared to medical therapy alone in chronic coronary syndromes.