Chronic stable angina percutaneous coronary intervention versus medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
No edit summary
 
(23 intermediate revisions by 6 users not shown)
Line 1: Line 1:
__NOTOC__
{{Chronic stable angina}}
{{Chronic stable angina}}


{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]  
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Lakshmi Gopalakrishnan, M.B.B.S.]]  


==Overview==
==Overview==
An increased risk of mortality and morbidity is associated with untreated [[coronary artery disease]].<ref name="pmid7600846">Moliterno DJ, Elliott JM (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7600846 Randomized trials of myocardial revascularization.] ''Curr Probl Cardiol'' 20 (3):125-90. PMID: [http://pubmed.gov/7600846 7600846]</ref> The main aim of therapy in patients with [[Chronic stable angina definition|chronic stable angina]] is to alleviate [[Chronic stable angina symptoms|symptoms]], delay the progression of [[atherosclerosis]], reduce the incidence of adverse coronary events and improve [[Chronic stable angina prognosis|prognosis]]. This is achieved either by [[Chronic stable angina pharmacotherapy overview|medical therapy]] or by revascularization procedures such as [[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|percutaneous coronary intervention]] or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|coronary artery bypass grafting]]. Medical therapy alleviates symptom and improves prognosis; however, on the contrary, revascularization procedures provide symptomatic relief but generally does not improve mortality.  
An increased risk of mortality and morbidity is associated with untreated [[coronary artery disease]].<ref name="pmid7600846">Moliterno DJ, Elliott JM (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7600846 Randomized trials of myocardial revascularization.] ''Curr Probl Cardiol'' 20 (3):125-90. PMID: [http://pubmed.gov/7600846 7600846]</ref> The main aim of therapy in patients with [[Chronic stable angina definition|chronic stable angina]] is to alleviate [[Chronic stable angina symptoms|symptoms]], delay the progression of [[atherosclerosis]], reduce the incidence of adverse coronary events and improve [[Chronic stable angina prognosis|prognosis]]. This may be achieved with either initial [[Chronic stable angina medical therapy|medical therapy]] or with initial revascularization that includes [[Chronic stable angina revascularization percutaneous coronary intervention|percutaneous coronary intervention]] or [[Chronic stable angina revascularization coronary artery bypass grafting|coronary artery bypass grafting]]. Medical therapy alleviates symptom and improves prognosis; however, on the contrary, revascularization procedures provide symptomatic relief but generally does not improve mortality.  


==Limitations of Older Trials==
==PCI vs Medical Therapy==
===Limitations of Older Trials===
There are some reservations to the application of results from older trials to the current clinical practice. Listed below are a few of the important limitations.
There are some reservations to the application of results from older trials to the current clinical practice. Listed below are a few of the important limitations.


*The patient population evaluated in older trials was confined to patients with preserved [[EF|left ventricular function]] and [[CAD|focal coronary artery disease]] and hence, its difficult to conclude the same results in patients with [[CAD|diffuse coronary artery disease]] and/or patients with [[left ventricular dysfunction]].
*The patient population evaluated in older trials was confined to patients with preserved [[EF|left ventricular function]] and [[CAD|focal coronary artery disease]]. It is therefore, difficult to generalize the same results in patients with [[CAD|diffuse coronary artery disease]] and/or patients with [[left ventricular dysfunction]].


*Majority of the patients evaluated in earlier trials underwent coronary angioplasty alone without stenting and even in a few trials that compared the benefit of PCI with concurrent [[BMS|bare-metal stent]]; involved patients who did not receive the current anti-thrombotic regimen.
*The majority of the patients evaluated in earlier trials underwent coronary angioplasty alone without stenting and even in a few trials prior to ''[[Clinical Outcomes Utilizing Revascularization And Aggressive Drug Evaluation|COURAGE]]'' that compared the benefit of PCI with concurrent [[BMS|bare-metal stenting]]; involved patients who did not receive the current optimal medical regimen and lifestyle intervention. The rate of progression of [[CAD|native coronary artery disease]] adversely affects the clinical outcome.<ref name="pmid10483952">Burek KA, Sutton-Tyrrell K, Brooks MM, Naydeck B, Keller N, Sellers MA et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10483952 Prognostic importance of lower extremity arterial disease in patients undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI).] ''J Am Coll Cardiol'' 34 (3):716-21. PMID: [http://pubmed.gov/10483952 10483952]</ref> Regardless of the treatment strategy employed, all patients with [[coronary artery disease]] should receive aggressive [[Chronic stable angina secondary prevention|risk factor modification]] which includes [[Chronic stable angina treatment aspirin|low dose aspirin]], [[Chronic stable angina treatment blood pressure control|blood pressure control]], [[Chronic stable angina treatment lipid management|lipid control]], [[Chronic stable angina treatment smoking cessation|tobacco cessation]], [[Chronic stable angina treatment weight management|weight loss]], [[Chronic stable angina treatment physical activity|regular exercise]] and [[Chronic stable angina treatment diabetes control|glycemic control]].


==Clinical trials comparing PCI versus Medical therapy==
===Clinical Trial Data: PCI vs Medical Therapy===
*In the '''ACME trial''' (1992), approximately 213 patients with [[CAD|stable single-vessel CAD]] were assessed to compare the effects of [[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|PCI]] with [[Chronic stable angina pharmacotherapy overview|medical therapy]] on [[Chronic stable angina definition|angina]] and [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise tolerance]]. The study demonstrated that PCI significantly reduced the incidence of anginal symptoms compared to medical therapy ''(50% angina free in PCI group  versus 24% in medically treated group)'' at one month and a sustained significant benefit was observed at 6 month follow-up  ''(64% angina free in PCI group versus 46% in medically treated group; p=less than 0.01)''. Patients treated with PCI were associated with better exercise duration of 2.1 minutes which was significantly greater than the 0.5 minute experienced in the medically treated group ''(p=less than 0.0001)''. Thus, the study concluded that PCI offered earlier and more complete relief of angina than medical therapy and was associated with a better exercise tolerance.<ref name="pmid1345754">Parisi AF, Folland ED, Hartigan P (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1345754 A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.] ''N Engl J Med'' 326 (1):10-6. [http://dx.doi.org/10.1056/NEJM199201023260102 DOI:10.1056/NEJM199201023260102] PMID: [http://pubmed.gov/1345754 1345754]</ref>
Based on the six-major randomized clinical trials such as ''ACME'' trial (1992 & 1997),<ref name="pmid1345754">Parisi AF, Folland ED, Hartigan P (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1345754 A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.] ''N Engl J Med'' 326 (1):10-6. [http://dx.doi.org/10.1056/NEJM199201023260102 DOI:10.1056/NEJM199201023260102] PMID: [http://pubmed.gov/1345754 1345754]</ref><ref name="pmid9180111">Folland ED, Hartigan PM, Parisi AF (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9180111 Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. Veterans Affairs ACME InvestigatorS.] ''J Am Coll Cardiol'' 29 (7):1505-11. PMID: [http://pubmed.gov/9180111 9180111]</ref> ''RITA-2'' trial (1997),<ref name="pmid9274581"> (1997)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9274581Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants.] ''Lancet'' 350 (9076):461-8. PMID:[http://pubmed.gov/9274581 9274581]</ref> ''AVERT'' trial (1999),<ref name="pmid10395630">Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10395630 Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators.] ''N Engl J Med'' 341 (2):70-6. [http://dx.doi.org/10.1056/NEJM199907083410202DOI:10.1056/NEJM199907083410202] PMID: [http://pubmed.gov/10395630 10395630]</ref> and ''MASS-II'' trial (2004)<ref name="pmid15145093">Hueb W, Soares PR, Gersh BJ, César LA, Luz PL, Puig LB et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15145093 The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results.] ''J Am Coll Cardiol'' 43 (10):1743-51. [http://dx.doi.org/10.1016/j.jacc.2003.08.065 DOI:10.1016/j.jacc.2003.08.065] PMID: [http://pubmed.gov/15145093 15145093]</ref> the success rates for [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] varied between 80% and 100% and the associated complication rates varied between 0.01% and 2.8% for [[MI]] and between 1.5% and 2.8% for the need of immediate [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]].


*Other older trials compared PTCA to both limited (AVERT trial) and optimal medical interventions (RITA-2 and MASS II). The findings of these trials were that patients undergoing PTCA had similar rates of death and myocardial infarction as those on medical therapy and were less likely to have angina during the first few years.
The patient population evaluated in these trials had a preserved [[EF|left ventricular function]] with an [[EF]] range that varied between 65% and 76%. The [[Chronic stable angina medical therapy|medical therapy]] in all trials included the administration of [[Chronic stable angina#Treatment|anti-platelet agents]], [[Chronic stable angina treatment beta blockers|beta-blockers]], [[Chronic stable angina treatment nitrates|nitrates]], [[Chronic stable angina treatment calcium channel blockers|calcium channel blockers]] and only the ''AVERT'' trial<ref name="pmid10395630">Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10395630 Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators.] ''N Engl J Med'' 341 (2):70-6. [http://dx.doi.org/10.1056/NEJM199907083410202DOI:10.1056/NEJM199907083410202] PMID: [http://pubmed.gov/10395630 10395630]</ref> used an initial [[Chronic stable angina treatment anti-lipid agents|aggressive lipid-lowering therapy]].


*More recent literature provides comparison between the use of stents and medical management, however, there is few data examining the extensive use of drug eluting stents and current extensive antithrombotic regimens (clopidogrel and GP IIb/IIIa inhibitors). In the most recent trial, COURAGE<ref>Optimal medical therapy with or without PCI for stable coronary disease.
PCI has not been found to reduce the risk of death, [[myocardial infarction]] or other major cardiovascular events when used along with medical therapy as part of initial management in patients with stable [[coronary artery disease]].<ref name="pmid17387127">Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17387127 Optimal medical therapy with or without PCI for stable coronary disease.] ''N Engl J Med'' 356 (15):1503-16. [http://dx.doi.org/10.1056/NEJMoa070829 DOI:10.1056/NEJMoa070829] PMID: [http://pubmed.gov/17387127 17387127]</ref>


Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group.
More recent literature provides comparison between the use of stents and [[Chronic stable angina medical therapy|medical management]]; however, there are a few data examining the extensive use of [[Chronic stable angina revascularization drug eluting stents|drug eluting stents]] and current extensive anti-thrombotic regimens ([[Chronic stable angina revascularization adjunctive pharmacotherapy for percutaneous coronary intervention|clopidogrel and GP IIb/IIIa inhibitors]]). In the most recent ''COURAGE'' trial,<ref name="pmid17387127">Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17387127 Optimal medical therapy with or without PCI for stable coronary disease.] ''N Engl J Med'' 356 (15):1503-16. [http://dx.doi.org/10.1056/NEJMoa070829 DOI:10.1056/NEJMoa070829] PMID: [http://pubmed.gov/17387127 17387127]</ref> drug-eluting stents were used in only 15 percent of patients. However, the ''COURAGE'' trial has the data most applicable to the current practice. You can read more detail about the ''COURAGE'' trial, [[Clinical Outcomes Utilizing Revascularization And Aggressive Drug Evaluation|here]].


N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26.
====Randomized Controlled Trials====
*In the ''ACME'' trial (1992), approximately 107 patients with [[CAD|stable single-vessel CAD]] with [[EF|mean ejection fraction]] of 65%, [[MI|non-Q wave MI]] within 3-months, [[ischemia]] evidenced by [[ST segment depression]] greater than 3mm on [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise stress test]] and no history of previous [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]], were assessed to compare the effects of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] with [[Chronic stable angina medical therapy|medical therapy]] on [[Chronic stable angina definition|angina]] and [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise tolerance]] in patients with single-vessel CAD. Successful dilatation was achieved in 82%. The study demonstrated that PCI significantly reduced the incidence of anginal symptoms compared to medical therapy (50% angina free in PCI group  versus 24% in medically treated group) at one month and a sustained significant benefit was observed at 6 month follow-up (64% angina free in PCI group versus 46% in medically treated group; p=less than 0.01). Patients treated with PCI were associated with better exercise duration of 2.1 minutes which was significantly greater than the 0.5 minute experienced in the medically treated group (p=less than 0.0001). However, complications related to PCI was the incidence of [[MI]] (1.0%), non-Q wave MI (3.0%) and need for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] (2.0%). Thus, the study concluded that PCI offered earlier and more complete relief of angina than medical therapy and was associated with a better exercise tolerance.<ref name="pmid1345754">Parisi AF, Folland ED, Hartigan P (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1345754 A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.] ''N Engl J Med'' 326 (1):10-6. [http://dx.doi.org/10.1056/NEJM199201023260102 DOI:10.1056/NEJM199201023260102] PMID: [http://pubmed.gov/1345754 1345754]</ref>


PMID: 17387127</ref>, drug-eluting stents were used in only 15 percent of patients. However, the COURAGE trial has the data most applicable to current practice. In this study 2287 patients were randomized to either aggressive medical therapy alone or aggressive medical therapy plus [[PCI]] with bare metal stenting. Patients were required to have both objective evidence of ischemia and significant CHD in a least one vessel; 87 percent were symptomatic and 58 percent had Canadian Cardiovascular Society [[CCS]] class II or III angina. Patients were excluded if they had [[CCS]] class IV angina, ≥50 percent left main disease, a markedly positive treadmill test (significant ST segment depressions and/or a hypotensive response during stage I of the Bruce protocol), an LVEF less than 30 percent, or coronary lesions deemed unsuitable for PCI. All patients received optimal medical therapy with beta blockers, calcium channel blockers, nitrates, antiplatelet therapy (either aspirin or clopidogrel), and aggressive lipid-lowering therapy with statin (attained median LDL-cholesterol was 72 mg/dL at five years). Exercise was recommended to achieve further improvements in the lipid profile when necessary.  The results were published at a median follow-up of 4.6 years. There was no significant difference between the two treatment strategies for the primary end point of death from any cause and non-fatal MI. There was no significant difference in the rates of hospitalization for ACS. Patients in the PCI group underwent significantly fewer subsequent revascularization procedures (21 versus 33 percent, HR 0.60, 95% CI 0.51-71).  
:*In a sub-study (1998) that assessed the long-term effectiveness of PCI for single-vessel [[CAD]], during a mean follow-up of 2.4 year for interview and 3.0 year for exercise testing after randomization, reported a significant angina-free period observed with the PCI group in comparison to the medically treated group (62% versus 47%; p=less than 0.05). Furthermore, exercise duration as measured by treadmill testing was prolonged by 1.33 minutes over baseline in the PCI group, whereas it decreased by 0.28 minutes in the medical group (p=less than 0.04). Thus, the study demonstrated sustained benefits with PCI similar to the ACME trial; hence, making it an attractive therapeutic option.<ref name="pmid9874045">Hartigan PM, Giacomini JC, Folland ED, Parisi AF (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9874045 Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine.] ''Am J Cardiol'' 82 (12):1445-50. PMID: [http://pubmed.gov/9874045 9874045]</ref>


*The issue of whether patients who receive [[PCI]] plus optimal medical therapy have a better quality of life and less angina than those who receive optimal medical therapy was addressed in COURAGE as well: At baseline, 22 percent of patients were free of angina. At three months, significantly more patients who received PCI were angina free (53 versus 42 percent), but at 36 months there was no significant difference (59 versus 56 percent). Patients in both groups showed significant improvements from baseline values in various measures of quality of life. The percent of patients with clinically significant improvement in parameters such as physical limitation, angina stability, angina frequency, and overall quality of life was significantly higher in the PCI group by the sixth months. However, there was no significant difference in these rates at 36 months. The results of COURAGE demonstrate that PCI with bare metal stents plus optimal medical therapy and initial, optimal medical therapy with revascularization as necessary are comparable strategies.
*In the ''ACME'' trial (1997), approximately 328 patients with [[chronic stable angina]] with [[EF|mean ejection fraction]] of 66%, presence of [[MI]] within the last 3-months, [[ischemia]] evidenced by [[ST segment depression]] greater than 3mm on [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise stress test]] and no history of prior [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]], were assessed to compare the effects of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] with [[Chronic stable angina medical therapy|medical therapy]] on [[Chronic stable angina definition|angina]] and [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|exercise tolerance]] in patients with double-vessel CAD. Successful dilatation was achieved in 69%. At 6-month follow-up, [[Chronic stable angina revascularization percutaneous coronary intervention|PCI-treated]] and [[Chronic stable angina medical therapy|medically treated]] patients with [[CAD|double-vessel disease]] demonstrated comparable improvement in exercise duration (+1.2 versus +1.3 min, respectively; P=0.89), freedom from [[chronic stable angina definition|angina]] (53% versus 36%, respectively; P=0.09) and improvement of overall quality of life score (+1.3 versus +4.4, respectively; P=0.32). Trends present at 6 months persisted at late 2-3 year follow-up. Patients undergoing double-vessel dilation had less complete initial [[Chronic stable angina revascularization|revascularization]] (45% versus 83%), greater average [[stenosis]] of worst lesions at 6-months (74% versus 56%) and demonstrated less improved [[Chronic stable angina myocardial perfusion scintigraphy|myocardial perfusion imaging]] (59% versus 75%). Thus, contrasting the greater advantages that favored [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] by these criteria in patients with [[CAD|single-vessel disease]] (P=0.0001 to 0.02).<ref name="pmid9180111">Folland ED, Hartigan PM, Parisi AF (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9180111 Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. Veterans Affairs ACME InvestigatorS.] ''J Am Coll Cardiol'' 29 (7):1505-11. PMID: [http://pubmed.gov/9180111 9180111]</ref>
 
*The ''AVERT'' trial (1999), demonstrated that in patients with [[Chronic stable angina assessing the pretest probability of coronary artery disease|low-risk]] for [[coronary artery disease]], an initial [[Chronic stable angina treatment anti-lipid agents|aggressive lipid-lowering therapy]] aimed at reversing plaque growth and promoting plaque stabilization, had significantly prolonged the time to first ischemic event (p=0.03) when compared to [[Chronic stable angina revascularization|PCI]] and [[Chronic stable angina medical therapy|standard medical therapy]]. Hence, in low-risk patients with stable [[CAD]], it is beneficial to start with medical therapy and reserve revascularization strategies for non-responders.<ref name="pmid10395630">Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10395630 Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators.] ''N Engl J Med'' 341 (2):70-6. [http://dx.doi.org/10.1056/NEJM199907083410202 DOI:10.1056/NEJM199907083410202] PMID: [http://pubmed.gov/10395630 10395630]</ref><ref name="pmid11174355">Amoroso G, Van Boven AJ, Crijns HJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11174355 Drug therapy or coronary angioplasty for the treatment of coronary artery disease: new insights.] ''Am Heart J'' 141 (2 Suppl):S22-5. PMID: [http://pubmed.gov/11174355 11174355]</ref>
 
:*Another randomized study (2004) that assessed PCI versus exercise training in patients with [[chronic stable angina definition|stable CAD]], demonstrated a 12-month program of regular physical exercise resulted in a significant benefit in the event-free survival (88% versus 70% in the PCI group; p=0.023) and the improvement in exercise capacity was achieved at a much lower cost (to gain 1 [[Canadian cardiovascular society classification of angina pectoris|CCS class]], 6956 dollars was spent in the PCI group versus 3429 dollars in the training group; p= less than 0.001).<ref name="pmid15007010">Hambrecht R, Walther C, Möbius-Winkler S, Gielen S, Linke A, Conradi K et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15007010 Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial.] ''Circulation'' 109 (11):1371-8. [http://dx.doi.org/10.1161/01.CIR.0000121360.31954.1F DOI:10.1161/01.CIR.0000121360.31954.1F] PMID: [http://pubmed.gov/15007010 15007010]</ref>
 
*Major trials such as the ''RITA-2''<ref name="pmid9274581"> (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9274581 Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants.] ''Lancet'' 350 (9076):461-8. PMID: [http://pubmed.gov/9274581 9274581]</ref> and ''MASS-II''<ref name="pmid15145093">Hueb W, Soares PR, Gersh BJ, César LA, Luz PL, Puig LB et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15145093 The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results.] ''J Am Coll Cardiol'' 43 (10):1743-51. [http://dx.doi.org/10.1016/j.jacc.2003.08.065 DOI:10.1016/j.jacc.2003.08.065] PMID: [http://pubmed.gov/15145093 15145093]</ref>, which used PCI as a method of revascularization reported similar rates of mortality and [[MI]] incidence observed in both the [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] and [[Chronic stable angina medical therapy|medically treated groups]]. However, the incidence of [[chronic stable angina definition|angina]] during the initial few years were significantly reduced in the PCI groups.  
:*The ''RITA-2'' trial (1997) compared the long-term effects of PCI and [[Chronic stable angina medical therapy|conventional medical therapy]] in patients with [[CAD]], demonstrated an early intervention with PCI was associated with greater symptomatic improvement, particularly observed in patients with more severe angina. However, on the contrary, the primary composite end-points during a median 2.7 year follow-up was significantly higher in patients treated with PCI than in patients treated with medical therapy (6.3% in the PCI group versus 3.3% in the medically treated group; p=0.02).<ref name="pmid9274581"> (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9274581 Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants.] ''Lancet'' 350 (9076):461-8. PMID: [http://pubmed.gov/9274581 9274581]</ref>
 
::*The quality of life did not improve significantly in the PCI group in comparison to the continued medical therapy group at 3-year follow-up. However, the substantial improvement in the physical functioning, vitality and general health observed with the PCI group at both 3-month and one-year follow-up was attributed to the alleviation of symptoms.<ref name="pmid10732887">Pocock SJ, Henderson RA, Clayton T, Lyman GH, Chamberlain DA (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10732887 Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina.] ''J Am Coll Cardiol'' 35 (4):907-14. PMID: [http://pubmed.gov/10732887 10732887]</ref>
 
::*At 7-year follow-up, similar rates of mortality and [[MI]] were observed in both the groups (14.5% in the PCI group versus 12.3% in the medically treated group; 95% CI -2.0% to +6.4%; p=0.21). However, there was sustained improvement in angina and exercise tolerance noted in the PCI group.<ref name="pmid14522473">Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14522473 Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy.] ''J Am Coll Cardiol'' 42 (7):1161-70. PMID: [http://pubmed.gov/14522473 14522473]</ref>
 
====Meta-analysis====
*A 2000 meta-analysis of six randomized controlled trials that assessed the benefit of PCI versus [[Chronic stable angina medical therapy|medical treatment]] for patients with [[CAD|non-acute coronary heart disease]], reported that [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may lead to a greater reduction in [[chronic stable angina definition|angina]] in patients with [[CAD]] in comparison to [[Chronic stable angina medical therapy|medical therapy]]; however, sufficient patients were not included to assess the effect of PCI on [[MI]], death, or subsequent [[Chronic stable angina revascularization|revascularization]].<ref name="pmid10884254">Bucher HC, Hengstler P, Schindler C, Guyatt GH (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10884254 Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials.] ''BMJ'' 321 (7253):73-7. PMID: [http://pubmed.gov/10884254 10884254]</ref>
 
*A 2005 meta-analysis of 11 randomized studies involving 2950 patients with [[chronic stable angina definition|stable CAD]] reported no significant difference between the [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] and [[Chronic stable angina medical therapy|medical therapy]] strategies with regard to mortality, incidence of [[MI]] or subsequent [[Chronic stable angina revascularization|revascularization]]. However, a possible survival benefit was seen with PCI only in trials that involved patients with recent [[myocardial infarction]] (RR 0.40; 95% CI 0.17 to 0.95). Except for PCI during follow-up, there was no significant between-study heterogeneity for any outcome.<ref name="pmid15927966">Katritsis DG, Ioannidis JP (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15927966 Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis.] ''Circulation'' 111 (22):2906-12. [http://dx.doi.org/10.1161/CIRCULATIONAHA.104.521864 DOI:10.1161/CIRCULATIONAHA.104.521864] PMID: [http://pubmed.gov/15927966 15927966]</ref>
 
*The results of the ''[[Clinical Outcomes Utilizing Revascularization And Aggressive Drug Evaluation|COURAGE]]'' trial were reflected in meta-analysis listed below.
:*A 2009 meta-analysis, assessed 61 PCI randomized trials involving 25,338 patients to compare the effect of PCI/PTCA (with [[BMS]] or [[DES]]) versus [[Chronic stable angina medical therapy|medical therapy]] in the management of patients with [[chronic stable angina|non-acute CAD]]. In all direct or indirect comparisons, succeeding advancements in [[Chronic stable angina revascularization percutaneous coronary intervention|percutaneous coronary intervention]] did not produce detectable improvements in the rate of mortality or [[myocardial infarction]] incidence. The risk ratio for indirect comparisons between DES and medical therapy was 0.96 (95% CI 0.60-1.52) for death and 1.15 (0.73-1.82) for myocardial infarction. Thereby, the results from this meta-analysis strengthened the strategy of initial management with optimal medical therapy before resorting to revascularization with PCI.<ref name="pmid19286090">Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, Nallamothu BK, Kent DM (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19286090 Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis.] ''Lancet'' 373 (9667):911-8. [http://dx.doi.org/10.1016/S0140-6736(09)60319-6 DOI:10.1016/S0140-6736(09)60319-6] PMID: [http://pubmed.gov/19286090 19286090]</ref>
 
:*A 2010 meta-analysis of 14 randomized trials evaluated the evidence of angina-relief from [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] compared to [[Chronic stable angina medical therapy|medical therapy]] in patients with [[chronic stable angina definition|stable CAD]]. The study reported that more patients were angina free after PCI than compared to medical therapy alone (OR 1.69; 95% CI, 1.24 to 2.30). The incremental benefit of PCI observed in recent trials (OR 1.13; CI, 0.76 to 1.68 ) was substantially reduced in comparison to older trials performed before the year 2000 (OR 3.38; CI, 1.89 to 6.04).<ref name="pmid20231568">Wijeysundera HC, Nallamothu BK, Krumholz HM, Tu JV, Ko DT (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20231568 Meta-analysis: effects of percutaneous coronary intervention versus medical therapy on angina relief.] ''Ann Intern Med'' 152 (6):370-9. [http://dx.doi.org/10.1059/0003-4819-152-6-201003160-00007 DOI:10.1059/0003-4819-152-6-201003160-00007] PMID: [http://pubmed.gov/20231568 20231568]</ref>
 
:* A 2012 meta-analysis of 8 randomized trials established no evidence of benefit of use of initial stent implantation for stable [[coronary artery disease]] compared with initial medical therapy for prevention of death, non fatal MI, unplanned revascularization, or angina. The respective event rates for death with stent implantation and medical therapy were 8.9% and 9.1% (OR, 0.98; 95% CI, 0.84-1.16); for nonfatal MI, 8.9% and 8.1% (OR, 1.12; 95% CI, 0.93-1.34); for unplanned revascularization, 21.4% and 30.7% (OR, 0.78; 95% CI, 0.57-1.06); and for persistent angina, 29% and 33% (OR, 0.80; 95% CI, 0.60-1.05).<ref name="pmid22371919">{{cite journal| author=Stergiopoulos K, Brown DL| title=Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. | journal=Arch Intern Med | year= 2012 | volume= 172 | issue= 4 | pages= 312-9 | pmid=22371919 | doi=10.1001/archinternmed.2011.1484 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22371919  }} </ref>


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
[[Category:Disease]]
[[Category:Ischemic heart diseases]]
[[Category:Ischemic heart diseases]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
 
[[Category:Intensive care medicine]]
{{WikiDoc Help Menu}}
[[Category:Up-To-Date]]
{{WikiDoc Sources}}
[[Category:Up-To-Date cardiology]]

Latest revision as of 21:26, 5 February 2013

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

Overview

Historical Perspective

Classification

Classic
Chronic Stable Angina
Atypical
Walk through Angina
Mixed Angina
Nocturnal Angina
Postprandial Angina
Cardiac Syndrome X
Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

PCI
CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

Patient Follow-Up
Rehabilitation

Secondary Prevention

Guidelines for Asymptomatic Patients

Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

Landmark Trials

Case Studies

Case #1

Chronic stable angina percutaneous coronary intervention versus medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chronic stable angina percutaneous coronary intervention versus medical therapy

CDC onChronic stable angina percutaneous coronary intervention versus medical therapy

Chronic stable angina percutaneous coronary intervention versus medical therapy in the news

Blogs on Chronic stable angina percutaneous coronary intervention versus medical therapy

to Hospitals Treating Chronic stable angina percutaneous coronary intervention versus medical therapy

Risk calculators and risk factors for Chronic stable angina percutaneous coronary intervention versus medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

An increased risk of mortality and morbidity is associated with untreated coronary artery disease.[1] The main aim of therapy in patients with chronic stable angina is to alleviate symptoms, delay the progression of atherosclerosis, reduce the incidence of adverse coronary events and improve prognosis. This may be achieved with either initial medical therapy or with initial revascularization that includes percutaneous coronary intervention or coronary artery bypass grafting. Medical therapy alleviates symptom and improves prognosis; however, on the contrary, revascularization procedures provide symptomatic relief but generally does not improve mortality.

PCI vs Medical Therapy

Limitations of Older Trials

There are some reservations to the application of results from older trials to the current clinical practice. Listed below are a few of the important limitations.

Clinical Trial Data: PCI vs Medical Therapy

Based on the six-major randomized clinical trials such as ACME trial (1992 & 1997),[3][4] RITA-2 trial (1997),[5] AVERT trial (1999),[6] and MASS-II trial (2004)[7] the success rates for PCI varied between 80% and 100% and the associated complication rates varied between 0.01% and 2.8% for MI and between 1.5% and 2.8% for the need of immediate CABG.

The patient population evaluated in these trials had a preserved left ventricular function with an EF range that varied between 65% and 76%. The medical therapy in all trials included the administration of anti-platelet agents, beta-blockers, nitrates, calcium channel blockers and only the AVERT trial[6] used an initial aggressive lipid-lowering therapy.

PCI has not been found to reduce the risk of death, myocardial infarction or other major cardiovascular events when used along with medical therapy as part of initial management in patients with stable coronary artery disease.[8]

More recent literature provides comparison between the use of stents and medical management; however, there are a few data examining the extensive use of drug eluting stents and current extensive anti-thrombotic regimens (clopidogrel and GP IIb/IIIa inhibitors). In the most recent COURAGE trial,[8] drug-eluting stents were used in only 15 percent of patients. However, the COURAGE trial has the data most applicable to the current practice. You can read more detail about the COURAGE trial, here.

Randomized Controlled Trials

  • In the ACME trial (1992), approximately 107 patients with stable single-vessel CAD with mean ejection fraction of 65%, non-Q wave MI within 3-months, ischemia evidenced by ST segment depression greater than 3mm on exercise stress test and no history of previous PCI, were assessed to compare the effects of PCI with medical therapy on angina and exercise tolerance in patients with single-vessel CAD. Successful dilatation was achieved in 82%. The study demonstrated that PCI significantly reduced the incidence of anginal symptoms compared to medical therapy (50% angina free in PCI group versus 24% in medically treated group) at one month and a sustained significant benefit was observed at 6 month follow-up (64% angina free in PCI group versus 46% in medically treated group; p=less than 0.01). Patients treated with PCI were associated with better exercise duration of 2.1 minutes which was significantly greater than the 0.5 minute experienced in the medically treated group (p=less than 0.0001). However, complications related to PCI was the incidence of MI (1.0%), non-Q wave MI (3.0%) and need for CABG (2.0%). Thus, the study concluded that PCI offered earlier and more complete relief of angina than medical therapy and was associated with a better exercise tolerance.[3]
  • In a sub-study (1998) that assessed the long-term effectiveness of PCI for single-vessel CAD, during a mean follow-up of 2.4 year for interview and 3.0 year for exercise testing after randomization, reported a significant angina-free period observed with the PCI group in comparison to the medically treated group (62% versus 47%; p=less than 0.05). Furthermore, exercise duration as measured by treadmill testing was prolonged by 1.33 minutes over baseline in the PCI group, whereas it decreased by 0.28 minutes in the medical group (p=less than 0.04). Thus, the study demonstrated sustained benefits with PCI similar to the ACME trial; hence, making it an attractive therapeutic option.[9]
  • Another randomized study (2004) that assessed PCI versus exercise training in patients with stable CAD, demonstrated a 12-month program of regular physical exercise resulted in a significant benefit in the event-free survival (88% versus 70% in the PCI group; p=0.023) and the improvement in exercise capacity was achieved at a much lower cost (to gain 1 CCS class, 6956 dollars was spent in the PCI group versus 3429 dollars in the training group; p= less than 0.001).[11]
  • Major trials such as the RITA-2[5] and MASS-II[7], which used PCI as a method of revascularization reported similar rates of mortality and MI incidence observed in both the PCI and medically treated groups. However, the incidence of angina during the initial few years were significantly reduced in the PCI groups.
  • The RITA-2 trial (1997) compared the long-term effects of PCI and conventional medical therapy in patients with CAD, demonstrated an early intervention with PCI was associated with greater symptomatic improvement, particularly observed in patients with more severe angina. However, on the contrary, the primary composite end-points during a median 2.7 year follow-up was significantly higher in patients treated with PCI than in patients treated with medical therapy (6.3% in the PCI group versus 3.3% in the medically treated group; p=0.02).[5]
  • The quality of life did not improve significantly in the PCI group in comparison to the continued medical therapy group at 3-year follow-up. However, the substantial improvement in the physical functioning, vitality and general health observed with the PCI group at both 3-month and one-year follow-up was attributed to the alleviation of symptoms.[12]
  • At 7-year follow-up, similar rates of mortality and MI were observed in both the groups (14.5% in the PCI group versus 12.3% in the medically treated group; 95% CI -2.0% to +6.4%; p=0.21). However, there was sustained improvement in angina and exercise tolerance noted in the PCI group.[13]

Meta-analysis

  • A 2005 meta-analysis of 11 randomized studies involving 2950 patients with stable CAD reported no significant difference between the PCI and medical therapy strategies with regard to mortality, incidence of MI or subsequent revascularization. However, a possible survival benefit was seen with PCI only in trials that involved patients with recent myocardial infarction (RR 0.40; 95% CI 0.17 to 0.95). Except for PCI during follow-up, there was no significant between-study heterogeneity for any outcome.[15]
  • The results of the COURAGE trial were reflected in meta-analysis listed below.
  • A 2009 meta-analysis, assessed 61 PCI randomized trials involving 25,338 patients to compare the effect of PCI/PTCA (with BMS or DES) versus medical therapy in the management of patients with non-acute CAD. In all direct or indirect comparisons, succeeding advancements in percutaneous coronary intervention did not produce detectable improvements in the rate of mortality or myocardial infarction incidence. The risk ratio for indirect comparisons between DES and medical therapy was 0.96 (95% CI 0.60-1.52) for death and 1.15 (0.73-1.82) for myocardial infarction. Thereby, the results from this meta-analysis strengthened the strategy of initial management with optimal medical therapy before resorting to revascularization with PCI.[16]
  • A 2010 meta-analysis of 14 randomized trials evaluated the evidence of angina-relief from PCI compared to medical therapy in patients with stable CAD. The study reported that more patients were angina free after PCI than compared to medical therapy alone (OR 1.69; 95% CI, 1.24 to 2.30). The incremental benefit of PCI observed in recent trials (OR 1.13; CI, 0.76 to 1.68 ) was substantially reduced in comparison to older trials performed before the year 2000 (OR 3.38; CI, 1.89 to 6.04).[17]
  • A 2012 meta-analysis of 8 randomized trials established no evidence of benefit of use of initial stent implantation for stable coronary artery disease compared with initial medical therapy for prevention of death, non fatal MI, unplanned revascularization, or angina. The respective event rates for death with stent implantation and medical therapy were 8.9% and 9.1% (OR, 0.98; 95% CI, 0.84-1.16); for nonfatal MI, 8.9% and 8.1% (OR, 1.12; 95% CI, 0.93-1.34); for unplanned revascularization, 21.4% and 30.7% (OR, 0.78; 95% CI, 0.57-1.06); and for persistent angina, 29% and 33% (OR, 0.80; 95% CI, 0.60-1.05).[18]

References

  1. ↑ Moliterno DJ, Elliott JM (1995) Randomized trials of myocardial revascularization. Curr Probl Cardiol 20 (3):125-90. PMID: 7600846
  2. ↑ Burek KA, Sutton-Tyrrell K, Brooks MM, Naydeck B, Keller N, Sellers MA et al. (1999) Prognostic importance of lower extremity arterial disease in patients undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI). J Am Coll Cardiol 34 (3):716-21. PMID: 10483952
  3. ↑ 3.0 3.1 Parisi AF, Folland ED, Hartigan P (1992) A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators. N Engl J Med 326 (1):10-6. DOI:10.1056/NEJM199201023260102 PMID: 1345754
  4. ↑ 4.0 4.1 Folland ED, Hartigan PM, Parisi AF (1997) Percutaneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. Veterans Affairs ACME InvestigatorS. J Am Coll Cardiol 29 (7):1505-11. PMID: 9180111
  5. ↑ 5.0 5.1 5.2 (1997)angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants. Lancet 350 (9076):461-8. PMID:9274581
  6. ↑ 6.0 6.1 6.2 Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM et al. (1999)Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators. N Engl J Med 341 (2):70-6. [1] PMID: 10395630
  7. ↑ 7.0 7.1 Hueb W, Soares PR, Gersh BJ, César LA, Luz PL, Puig LB et al. (2004) The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol 43 (10):1743-51. DOI:10.1016/j.jacc.2003.08.065 PMID: 15145093
  8. ↑ 8.0 8.1 Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ et al. (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356 (15):1503-16. DOI:10.1056/NEJMoa070829 PMID: 17387127
  9. ↑ Hartigan PM, Giacomini JC, Folland ED, Parisi AF (1998) Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine. Am J Cardiol 82 (12):1445-50. PMID: 9874045
  10. ↑ Amoroso G, Van Boven AJ, Crijns HJ (2001) Drug therapy or coronary angioplasty for the treatment of coronary artery disease: new insights. Am Heart J 141 (2 Suppl):S22-5. PMID: 11174355
  11. ↑ Hambrecht R, Walther C, Möbius-Winkler S, Gielen S, Linke A, Conradi K et al. (2004) Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 109 (11):1371-8. DOI:10.1161/01.CIR.0000121360.31954.1F PMID: 15007010
  12. ↑ Pocock SJ, Henderson RA, Clayton T, Lyman GH, Chamberlain DA (2000) Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina. J Am Coll Cardiol 35 (4):907-14. PMID: 10732887
  13. ↑ Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG et al. (2003) Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy. J Am Coll Cardiol 42 (7):1161-70. PMID: 14522473
  14. ↑ Bucher HC, Hengstler P, Schindler C, Guyatt GH (2000) Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials. BMJ 321 (7253):73-7. PMID: 10884254
  15. ↑ Katritsis DG, Ioannidis JP (2005) Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis. Circulation 111 (22):2906-12. DOI:10.1161/CIRCULATIONAHA.104.521864 PMID: 15927966
  16. ↑ Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, Nallamothu BK, Kent DM (2009) Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet 373 (9667):911-8. DOI:10.1016/S0140-6736(09)60319-6 PMID: 19286090
  17. ↑ Wijeysundera HC, Nallamothu BK, Krumholz HM, Tu JV, Ko DT (2010) Meta-analysis: effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med 152 (6):370-9. DOI:10.1059/0003-4819-152-6-201003160-00007 PMID: 20231568
  18. ↑ Stergiopoulos K, Brown DL (2012). "Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials". Arch Intern Med. 172 (4): 312–9. doi:10.1001/archinternmed.2011.1484. PMID 22371919.

Template:WikiDoc Sources

Retrieved from "https://www.wikidoc.org/index.php?title=Chronic_stable_angina_percutaneous_coronary_intervention_versus_medical_therapy&oldid=842513"