Appropriate revascularization in stable angina: lessons from the BARI 2D trial

Area of Science:

• Cardiology
• Interventional Cardiology
• Clinical Trials

Background:

• Stable ischemic heart disease guidelines recommend optimal medical management (OMT) before revascularization.
• The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial found no difference in major cardiovascular events between initial OMT and initial revascularization.
• Nearly 40% of patients in the OMT group eventually underwent revascularization.

Purpose of the Study:

• To identify patient subgroups who might benefit from direct revascularization without a trial of OMT.
• To analyze factors predicting revascularization in patients with stable ischemic heart disease undergoing OMT.

Main Methods:

• Analysis of 1192 patients randomized to OMT in the BARI 2D trial.
• Multivariate logistic analysis and Cox regression models using baseline data.
• Landmark analysis of participants not revascularized at 6 months.

Main Results:

• Baseline data had limited predictive value for revascularization.
• Incorporating angina severity during the first 6 months improved prediction of revascularization (C statistic = 0.789).

Conclusions:

• The analysis supports a trial of OMT before revascularization for most stable ischemic heart disease patients.
• Severe angina and proximal left anterior descending artery disease may be exceptions.
• Close follow-up during OMT effectively identified patients requiring revascularization.