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Published on: January 28, 2020
Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome
Ana Gabaldon-Perez1, Victor Marcos-Garces1, Jose Gavara2,3
1Department of Cardiology, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain.
Insights
Coronary revascularization reduces mortality in acute heart conditions but offers limited benefits for chronic ischemic heart disease (IHD) survival. Invasive strategies are best reserved for patients with persistent symptoms or high-risk factors despite optimal medical treatment.
Area of Science:
- Cardiology
- Cardiovascular Medicine
- Interventional Cardiology
Background:
- Ischemic heart disease (IHD) remains a primary cause of mortality globally.
- Coronary revascularization, including CABG and PCI, has significantly reduced IHD mortality, particularly in acute coronary syndromes (ACS).
- The efficacy of routine revascularization in chronic coronary syndromes (CCS) is debated, despite over 40 years of research.
Purpose of the Study:
- To evaluate the long-term impact of routine coronary revascularization versus optimal medical treatment (OMT) in patients with chronic coronary syndromes (CCS).
- To determine the role of invasive management in improving survival and symptomatic outcomes in CCS.
- To provide evidence-based recommendations for the selection of patients who may benefit from revascularization in CCS.
Main Methods:
- Systematic review and meta-analysis of clinical trials comparing OMT alone with OMT plus routine coronary revascularization (CABG or PCI) in CCS patients.
- Analysis of mortality rates, event incidence, and symptomatic improvement across different treatment strategies.
- Assessment of patient-specific factors, including left ventricular function, coronary anatomy, and functional status.
Main Results:
- Routine invasive management in CCS has not shown a significant reduction in mortality compared to OMT alone.
- Revascularization provides symptomatic improvement and reduces minor events in some CCS patients.
- Evidence suggests that the benefits of revascularization in CCS are controversial regarding long-term survival.
Conclusions:
- Invasive management for CCS should be reserved for patients with uncontrolled symptoms despite OMT or those with high-risk features.
- Patient expectations and preferences are crucial in decision-making for revascularization in CCS.
- Optimal medical treatment remains the cornerstone for managing most patients with chronic ischemic heart disease.
Abstract:
Ischemic heart disease (IHD) persists as the leading cause of death in the Western world. In recent decades, great headway has been made in reducing mortality due to IHD, based around secondary prevention. The advent of coronary revascularization techniques, first coronary artery bypass grafting (CABG) surgery in the 1960s and then percutaneous coronary intervention (PCI) in the 1970s, has represented one of the major breakthroughs in medicine during the last century. The benefit provided by these techniques, especially PCI, has been crucial in lowering mortality rates in acute coronary syndrome (ACS). However, in the setting where IHD is most prevalent, namely chronic coronary syndrome (CCS), the increase in life expectancy provided by coronary revascularization is controversial. Over more than 40 years, several clinical trials have been carried out comparing optimal medical treatment (OMT) alone with a strategy of routine coronary revascularization on top of OMT. Beyond a certain degree of symptomatic improvement and lower incidence of minor events, routine invasive management has not demonstrated a convincing effect in terms of reducing mortality in CCS. Based on the accumulated evidence more than half a century after the first revascularization procedures were used, invasive management should be considered in those patients with uncontrolled symptoms despite OMT or high-risk features related to left ventricular function, coronary anatomy, or functional assessment, taking into account the patient expectations and preferences.
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