The uncertain efficacy surrounding percutaneous coronary intervention (PCI) for patients with stable ischemic coronary artery disease means medical management should be the norm, a review article suggested.
William S. Weintraub, MD, of Christiana Care Health System in Newark, Del., and William E. Boden, MD, of New York’s Albany Medical College, cited the lack of survival and cardiovascular benefits in this population after PCI, as demonstrated by randomized studies like their COURAGE trial.
“Until further research can show that PCI can reduce cardiovascular events in these patients, a first-line strategy of optimal medical therapy is known to be safe, effective, and noninferior to PCI, and our practice should more closely follow this strategy,” according to their review appearing online in JAMA Internal Medicine.
“We need to avoid the ‘therapeutic illusion’ that we are accomplishing more than is shown by the evidence,” they wrote. “PCI for stable patients remains principally a treatment of limited benefit for angina, and probably no benefit for asymptomatic patients. Furthermore, the finite risk of complications (such as coronary dissection, stent thrombosis, MI, access site complications, and death) persists, such that the risk vs benefit analysis in the otherwise stable patient becomes tenuous. Are we adequately counseling patients about the uncertain benefits but known risks prior to offering PCI?”
Each procedure costs at least $15,000 under Medicare. “With uncertain benefits and high costs, this can only be a low-value intervention at best, and a waste of money at worst,” they added.
Furthermore, “how PCI could reduce long-term mortality or prevent myocardial infarction [MI] is not clear because sites of future plaque rupture leading to myocardial infarction are unpredictable and PCI can only treat localized anatomic segments of obstructive atherosclerosis.” This is true even in “selected, high-risk patients,” who have more severe ischemia, they wrote.
Yet Weintraub and Boden noted that the ongoing ISCHEMIA trial should provide some, but not all, of the answers.
“However, ISCHEMIA will probably not be able to investigate the dynamic interplay between the extent and severity of ischemia and the presence of vulnerable plaques. In addition, ISCHEMIA will not be powered for the singular end point of mortality. With a primary composite outcome that includes nonfatal MI and cardiovascular mortality, ISCHEMIA may have similar limitations with the nonfatal MI component that has been a source of criticism in COURAGE.”
The authors maintained that this study is nevertheless “our best hope for obtaining additional, much-needed evidence to inform clinical practice.”
Weintraub and Boden reported no relevant conflicts of interest.
JAMA Internal Medicine
Weintraub WS, et al “Reexamining the efficacy and value of percutaneous coronary intervention for patients with stable ischemic heart disease” JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2016.3071.