The Role of PCI in SIHD

Herbert T, Rizzolo D
The Role of Percutaneous Coronary Intervention in Managing Patients With Stable Ischemic Heart Disease. JAAPA 2020;33:18-22.

The following are key points to remember from this article that reviews important principles undergirding contemporary use of percutaneous coronary intervention (PCI) and its limited role in the management of stable ischemic heart disease (SIHD):

  1. In the initial evaluation of patients with chest pain, clinicians should distinguish between stable and unstable disease. In all patients with SIHD, guideline-directed medical therapy (GDMT) is recommended.
  2. Class I recommendations for GDMT include management of lipids, blood pressure, and weight; smoking cessation; physical activity; yearly flu shots; and antiplatelet therapy. If indicated, patients should be treated with beta-blocker, renin-angiotensin-aldosterone system blockade, and treatment to relieve symptoms (i.e., beta-blocker, long-acting nitrate, calcium-channel blocker, and sublingual nitroglycerin).
  3. Patients with suspected SIHD should undergo stress testing if high-risk coronary lesion is suggested by symptoms, risk factors, comorbidities, or known cardiac disease. If cardiac stress test results suggest high-risk coronary lesion and the patient is a candidate for and amenable to a revascularization strategy, then proceed with coronary angiography. If stress test does not show evidence of high-risk coronary lesion, GDMT should be titrated as tolerated and symptoms reassessed at follow-up.
  4. PCI has a well-established role in acute coronary syndrome. In SIHD, guidelines recommend PCI as follows:
    • To improve survival in patients with ≥50% non-complex stenosis of the (unprotected) left main coronary artery who are not candidates for coronary artery bypass surgery
    • To alleviate symptoms in patients with coronary stenosis ≥70% or fractional flow reserve (FFR) <0.8 with unacceptable anginal symptoms that compromise their quality of life
  5. Clinical trials provide the basis for these recommendations. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trials showed that in SIHD, PCI plus GDMT provides no survival benefit over GDMT alone and did not reduce rates of non-fatal myocardial infarction (COURAGE) or major cardiovascular events (BARI 2D) at 5 years.
  6. The FAME 2 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2) trial showed that patients with SIHD and FFR <0.8 treated with GDMT plus PCI (with second-generation drug-eluting stent) were less likely to require subsequent urgent revascularization than patients with FFR <0.8 treated with GDMT alone (4% vs. 16.3%).
  7. Bare-metal stent (BMS) is recommended for patients at high risk for bleeding or needing surgery soon because dual antiplatelet therapy is required for only 1 month following bare-metal stent implantation.
  8. According to the CathPCI Registry of nearly 1 million patients, overall PCI complication rate was 4.5% in patients without ST-segment elevation myocardial infarction.
  9. Benefits and risks of PCI should be clearly conveyed to patients. The benefit of PCI in providing more immediate angina relief appears short lived.
  10. Patients with SIHD who understand these benefits and risks are more likely to choose GDMT alone, which can eliminate needless complications and reduce costs of cardiac care.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Angina, Stable, Coronary Artery Disease, Percutaneous Coronary Intervention, Coronary Angiography, Stents, Exercise Test, Platelet Aggregation Inhibitors, Calcium Channel Blockers, Renin-Angiotensin System, Quality of Life

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