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Published on: February 18, 2020
Percutaneous coronary intervention for the management of stable ischemic heart disease
Shuangbo Liu1, Michael Tsang2, Husam Abdel-Qadir3
1Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario.
Insights
Percutaneous coronary intervention (PCI) offers no significant benefit over sham procedures for stable ischemic heart disease (SIHD) symptom relief. Further research is needed for higher-risk SIHD patients.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Stable ischemic heart disease (SIHD) management often involves percutaneous coronary intervention (PCI).
- Uncertainty exists regarding the prognostic and symptomatic benefits of routine PCI in SIHD patients.
Purpose of the Study:
- To review landmark studies and recent evidence on the benefits and drawbacks of routine PCI for SIHD.
- To evaluate the impact of PCI on symptoms and quality of life in SIHD patients.
Main Methods:
- Review of randomized controlled trials, including the ORBITA trial.
- Analysis of placebo-controlled trials investigating PCI versus sham procedures in single-vessel SIHD.
Main Results:
- The ORBITA trial found no significant difference in exercise time, angina, or quality of life between PCI and sham PCI in single-vessel SIHD.
- Recent evidence questions the established benefits of PCI for symptom improvement in SIHD.
Conclusions:
- PCI may not be a first-line or default strategy for symptomatic improvement in all SIHD patients.
- Ongoing trials like ISCHEMIA will further clarify the role of PCI in higher-risk SIHD patients.
Purpose Of Review:
The purpose of this review is to summarize landmark studies and recent evidence in support for and against benefits of routine percutaneous coronary intervention (PCI) in the management of patients with stable ischemic heart disease (SIHD).
Recent Findings:
Randomized controlled trials have raised uncertainty regarding the prognostic benefits of routine PCI in patients with SIHD. The benefits of PCI to improve symptoms and quality of life (QOL), thought to be more established, was brought into question recently by the ORBITA trial. Two hundred participants with single vessel SIHD optimized first on antianginal therapy were randomized to PCI or sham PCI procedure. At 6 weeks, there was no significant difference in the primary endpoint of exercise time increment (PCI minus sham PCI 16.6 s, 95% confidence interval -8.9 to 42.0 s, P = 0.20), or secondary endpoints of change in angina or QOL scores between the groups.
Summary:
Findings from this first placebo-controlled trial of PCI in patients with single vessel SIHD suggest that PCI need not necessarily be the first line or default strategy for symptomatic improvement. Results from the ongoing ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial will provide further guidance regarding symptomatic and prognostic benefits of early angiography and revascularization for higher risk SIHD patients with moderate-severe ischemia.
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