CORRESPONDENCE: LETTER TO THE EDITOR
Medical Therapy Versus Percutaneous Coronary Intervention for Patients With Stable Coronary Artery Disease
Armin Arbab-Zadeh, MD, FACC*
* Johns Hopkins University/Division of Cardiology, 600 North Wolfe Street/Blalock 524, Baltimore, Maryland 21287-0409 (Email: ArminZadeh{at}jhu.edu).
Schömig et al. (1) reported a meta-analysis addressing the mortality in patients with stable coronary artery disease randomized to medical therapy and coronary intervention involving 17 prospective studies. The investigators concluded that based on their data, "a PCI-based invasive strategy may improve long-term survival compared with a medical treatment-only strategy" (1).
In addition to the numerous flaws of this analysis pointed out by the accompanying editorial comment (2), the fundamental limitation lies in the fact that except for the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, none of the studies included in this analysis applied contemporary medical treatment. Even though the same can be said about the interventional strategy, the difference is that newer medical interventions, such as high-dose statins, dual platelet inhibition, adequate angiotensin-converting enzyme inhibition, and beta blockade, have shown in randomized prospective trials to reduce the risk of death and/or nonfatal myocardial infarction compared with the standard of care (3–5), while such randomized trials (including follow-up) failed to show reduction of death or myocardial infarction for newer interventional therapies, such as bare-metal or drug-eluting stenting (6–9).
The report by Schömig et al. (1) therefore is misleading and irrelevant for contemporary medical practice. We should accept that the COURAGE trial, despite some limitations, represents the best evidence currently available for guiding our approach to patients with stable coronary artery disease.
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1. Schömig A, Mehilli J, de Waha A, Seyfarth M, Pache J, Kastrati A. A meta-analysis of 17 randomized trials of a percutaneous coronary intervention-based strategy in patients with stable coronary artery disease J Am Coll Cardiol 2008;52:894-904.[Abstract/Free Full Text]2. O'Rourke RA. Optimal medical therapy is a proven option for chronic stable angina J Am Coll Cardiol 2008;52:905-907.[Abstract/Free Full Text] 3. Heart Protection Study Collaborative Group MRC/BHF heart protection study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial Lancet 2002;360:23-33.[CrossRef][Web of Science][Medline] 4. CAPRIE Steering Committee A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE) Lancet 1996;348:1329-1339.[CrossRef][Web of Science][Medline] 5. Fox KM, EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study) Lancet 2003;362:782-788.[CrossRef][Web of Science][Medline] 6. Fischman DL, Leon MB, Baim DS, et al. Stent Restenosis Study Investigators A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease N Engl J Med 1994;331:496-501.[Abstract/Free Full Text] 7. Serruys PW, de Jaegere P, Kiemeneij F, et al., on behalf of Benestent Study Group. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med;331:489–95. 8. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery N Engl J Med 2003;349:1315-1323.[Abstract/Free Full Text] 9. Stone GW, Ellis SG, Cox DA, et al. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease N Engl J Med 2004;350:221-231.[Abstract/Free Full Text]
Related Article
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- Albert Schömig and Adnan Kastrati
J. Am. Coll. Cardiol. 2009 53: 529.
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