Predictors of Medical Management in Patients Undergoing Elective Cardiac Catheterization for Chronic Ischemic Heart
Auras R Atreya1,2, Senthil K Sivalingam1, Sonali Arora1,2
1Division of Cardiovascular Medicine, Department of Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.
Insights
Percutaneous coronary intervention (PCI) for stable angina is guided by patient and lesion characteristics, not symptoms. Angiographic factors like distal or type C lesions favor medical management over PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Medicine
Background:
- Percutaneous coronary intervention (PCI) offers no mortality benefit over medical therapy for stable angina.
- PCI decisions should prioritize refractory symptoms over lesion characteristics.
Purpose of the Study:
- To test the hypothesis that angiographic lesion characteristics and stress test results influence PCI decisions more than symptom severity.
- To identify predictors of medical management versus PCI in stable angina patients.
Main Methods:
- Retrospective cohort study of 207 patients undergoing elective cardiac catheterization.
- Analysis of anginal symptoms, medical/antianginal therapy, stress tests, and ACC/AHA lesion types.
- Logistic regression to determine predictors of medical management.
Main Results:
- 163 patients underwent PCI, 44 received medical therapy.
- Medical management was associated with older age, chronic kidney disease, distal lesions, and ACC/AHA type C lesions.
- No association found with sex, race, symptoms, therapy intensity, or cardiologist type.
Conclusions:
- PCI decisions in stable angina are primarily driven by patient and angiographic factors, not symptoms or ischemia.
- Distal and high-risk (ACC/AHA type C) lesions are more frequently managed medically.
Background:
Compared with medical therapy, percutaneous coronary intervention (PCI) does not reduce mortality or myocardial infarction in patients with stable angina. Therefore, PCI should be guided by refractory anginal symptoms and not just lesion characteristics.
Hypothesis:
We hypothesized that angiographic lesion characteristics and stress test results would have a greater role in the decision to proceed with PCI than would symptom severity.
Methods:
We performed a retrospective cohort study of patients undergoing elective cardiac catheterization and possible PCI at an academic medical center. Anginal symptoms, optimal medical therapy, antianginal therapy, stress test results, and angiographic lesions (including American College of Cardiology/American Heart Association [ACC/AHA] lesion type) were analyzed. Logistic regression was used to determine predictors of medical management among patients not referred for coronary artery bypass surgery.
Results:
Of the 207 patients with obstructive lesions amenable to PCI, 163 underwent PCI and 44 were referred to medical therapy. In the multivariable logistic model, the following variables were associated with medical management: advancing age (odds ratio [OR] per 1 year: 0.94, 95% confidence interval [CI]: 0.91-0.98), chronic kidney disease (OR: 0.23, 95% CI: 0.06-0.95), distal location (OR: 0.21, 95% CI: 0.09-0.48), and ACC/AHA type C lesion (OR: 0.08, 95% CI: 0.03-0.22). There was no association with sex, race, symptoms, optimal medical therapy, maximal antianginal therapy, referral status, or type of interventional cardiologist (academic vs private practice).
Conclusions:
For patients undergoing cardiac catheterization for stable angina, the decision to proceed to PCI vs medical management appears to depend largely on patient and angiographic characteristics, but not on symptoms or ischemia. Distal and high-risk lesions (ACC/AHA type C) are more often referred for medical therapy.
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