Offer medical treatment first for adults with stable coronary artery disease

Each year, around 400 000 USA adults with stable angina have a percutaneous coronary intervention (PCI), despite increasing evidence that this procedure does not prolong survival, prevent heart attacks, or improve symptoms more than medical treatment alone. A new meta-analysis confined to trials that compared modern PCIs with modern drug protocols confirms that PCI, including stenting, does not benefit adults with stable coronary artery disease.

The authors and a linked editorial agree that the USA has a problem. While the government and funding agencies push hard for large comparative effectiveness trials, providers are busy ignoring the results, wilfully or otherwise. They must be persuaded to change direction, says the editorial. Guidelines already recommend best medical treatment first. Averting or deferring even a third of elective PCIs in stable patients would save the health economy between $6bn and $8bn a year.

The new meta-analysis pooled results from eight trials published in the past 10 years. Most adults assigned to PCI were given a bare metal stent plus recommended medical treatment. Adults assigned to drugs alone were prescribed similar treatments, which included aspirin, a statin, a β-blocker, and an angiotensin-converting enzyme inhibitor. Four-fifths of the participants were men.

Mortality during 4.3 years of follow-up was 8.9% in adults treated with PCI and 9.1% in those given recommended medical treatments alone (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.84 - 1.16). Around a third of both groups had enduring angina (29% v. 33%; OR 0.80, 95% CI 0.60 - 1.05). Between 8% and 9% had a non-fatal myocardial infarction (8.9% v. 8.1%; OR 1.12, 95% CI 0.93 - 1.34). Results for unplanned revascularisations were less clear cut (21.4% v. 30.7%; OR 0.78, 95% CI 0.57 - 1.06) but do not undermine the clear message from analyses of deaths and heart attacks, say the authors. Adults with stable angina or ischaemia that appears on stress tests should be offered the best available drugs first.

Stergiopoulos K, Brown DL. Arch Intern Med 2012;172:312-319.