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Published on: June 28, 2019
Revascularization in stable coronary artery disease
Rasha K Al-Lamee1,2, Michael Foley1,2, Christopher A Rajkumar1,2
1National Heart and Lung Institute, Imperial College London, UK.
Insights
For stable coronary artery disease (CAD), revascularization like bypass surgery may not prevent heart attacks or death as previously thought. Current evidence suggests a re-evaluation of these invasive procedures for stable CAD patients is needed.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Stable coronary artery disease (CAD) management traditionally involves medications to prevent myocardial infarction and death.
- Revascularization procedures, such as coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), were historically assumed to prevent adverse events and alleviate symptoms in stable CAD.
- Recent randomized controlled trials (RCTs) challenge these long-held assumptions regarding the benefits of revascularization.
Purpose of the Study:
- To critically evaluate the current evidence base for revascularization in stable coronary artery disease (CAD) in light of recent trial data.
- To examine the role of revascularization in high-risk patient groups for myocardial infarction and death.
- To identify uncertainties, research gaps, and potential communication issues in clinical practice.
Main Methods:
- Review and synthesis of evidence from recent randomized controlled trials, including the ISCHEMIA trial.
- Analysis of contemporary practice guidelines and recommendations for stable CAD.
- Focus on patient subgroups with high risk of adverse cardiovascular events.
Main Results:
- Recent RCTs, such as the ISCHEMIA trial, provide evidence that challenges the routine use of revascularization for stable CAD.
- The benefits of revascularization in preventing myocardial infarction and death in stable CAD patients are less certain than previously assumed.
- Specific patient groups may still benefit from revascularization, but clear indications require further investigation.
Conclusions:
- The evidence supporting revascularization for stable coronary artery disease (CAD) requires re-evaluation, particularly in light of the ISCHEMIA trial.
- Contemporary management should carefully consider the risks and benefits of revascularization versus optimal medical therapy.
- Further research is needed to clarify the role of revascularization in specific high-risk populations and to improve doctor-patient communication regarding treatment decisions.
Abstract:
Management of stable coronary artery disease (CAD) centers on medication to prevent myocardial infarction and death. Many anti-anginal medications also have benefit for reducing symptoms, and have been proven to be effective against placebo control. Before effective preventive medications were available, patients with stable CAD often underwent revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), on the plausible assumption that these procedures would prevent adverse events and reduce symptoms. However, recent randomized controlled trials have cast doubt on these assumptions.Considering results from the recent ISCHEMIA trial, we discuss the evidence base that underpins revascularization for stable CAD in contemporary practice. We also focus on patient groups at high risk of myocardial infarction and death, for whom revascularization is often recommended. We outline the areas of uncertainty, unanswered research questions, and key areas of potential miscommunication in doctor-patient consultations.
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