A 50-year-old male was evaluated in the office for chest pain. The patient reported substernal chest pressure sensation radiating to left inner arm with associated diaphoresis, brought on by moderate exertion, walking uphill or taking a flight of stairs, relieved by rest. Symptoms started three months ago, and remained stable in severity and fairly predictable. He has history of hypertension, diet controlled diabetes, and dyslipidemia. He is a lifelong non-smoker, and has no family history of premature coronary artery disease. Baseline EKG showed no ST-T abnormalities. Patient was referred for exercise stress testing. On modified Bruce protocol, patient walked for 8 minutes, developed similar chest pain, and 2 mm horizontal ST depression in leads V3-6. Patient was started on aspirin, metoprolol, and atorvastatin. On six weeks follow-up, patient reported minimal improvement in symptoms, and a long acting nitrate was added to the regimen. However, patient remained symptomatic with moderate exertion and was referred for coronary angiography. Coronary angiography revealed normal right coronary artery, left anterior descending in its mid segment had 40% stenosis, and second obtuse marginal branch showed a focal 90% stenosis. Patient underwent successful percutaneous coronary intervention of second OM lesion with a drug eluting stent.
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When comparing PCI + OMT (optimal medical therapy) with OMT alone in patients with stable ischemic heart disease, PCI + OMT is associated with:
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The correct answer is: B. No survival benefit, lower revascularization rates and better health status outcomes
The patient has stable ischemic heart disease with CCS class II angina symptoms, on optimal medical therapy (including two classes of anti-ischemic therapies). Patient has single vessel disease without involvement of proximal LAD, and moderate risk non-invasive stress test. PCI in this setting would be categorized as "Appropriate" as per the 2012 Appropriate Use Criteria for PCI.1 In a recent post-hoc analysis, authors mapped patient enrolled in COURAGE trial to "Appropriate", "Uncertain" and "Inappropriate" categories, and compared outcomes of PCI +OMT vs OMT alone.2 There were no differences noted in deaths or non-fatal MI in two groups (Choice A is not correct). However, Initial PCI strategy, when appropriate was associated with lower rate of revascularizaton and better health status, whereas uncertain PCI's were associated with lower revascularizaton rates, but similar health status compared to OMT (Choice C), and inappropriate PCI's are associated with similar revascularization and health status compared to OMT alone (Choice D).
References
Patel MR, Dehmer GJ, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59(9):857-81.
Bradley SM, Chan PS, et al. Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial). Am J Cardiol 2015;116(2):167-73.
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