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Introduction Revascularisation in patients with symptomatic stable coronary artery disease compared to optimal medical therapy remains controversial and practice is variable between clinicians. National guidance (NICE) recommends referral for revascularisation only if a patient is on maximal tolerated dose of two anti-anginal agents. ESC guidance however stipulates that in patients with chronic coronary syndrome, revascularisation should be an adjunct to optimal guideline directed medical therapy in those who remain symptomatic or whom revascularisation will improve prognosis. Our objective was to review local practice at our centre and evaluate whether patients referred for elective percutaneous coronary intervention (PCI) due to stable anginal symptoms are on optimal medical therapy (OMT) prior to attempted coronary revascularisation. Methods Patients were retrospectively identified from the British Cardiovascular Intervention Society (BCIS) database and included if they attended for elective PCI over a 12 month period. Patients were excluded if they had PCI for an acute coronary syndrome. Baseline demographic data were collected, procedural details and details of anti-anginal therapy pre angiography. Results 134 patients were included in this study, 108 (81%) were male and median age was 71 years. 17 (13%) patients had functional testing prior to PCI including stress echocardiography or stress CMR. Most patients had single vessel PCI (94%) (table 1). The majority of patients, 106 (79%) were on at least one first-line anti-anginal agent at baseline – defined as either a beta blocker, calcium- channel blocker or long-acting nitrate (table 2). 28 (21%) patients were not on any anti-anginal medication. 44 (33%) patients were on 3 anti-anginal agents and only 2 patients (1%) were on 4 agents at baseline. Following outpatient review, prior to planned PCI, only 21 patients (16%) had initiation of anti-anginal therapy or up-titration of existing therapy. In 10/21 patients a nitrate was added or increased and in 7/21 patients beta-blocker therapy was added or up-titrated. Conclusions Our study demonstrates that the majority of patients referred for elective revascularisation in the context of stable angina and chronic coronary artery disease were established one or two anti-anginal agents hence failed medical therapy. Of note, 21% patients were not on any anti-anginal therapy prior to PCI. The question remains as to whether further up-titration prior to PCI changes outcomes or symptom severity and whether a guideline directed OMT strategy should be pursued prior to revascularisation in this patient subgroup. Conflict of Interest None
Hampal et al. (Mon,) studied this question.