CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

February 27th, 2012

Meta-Analysis Finds No Advantages for PCI Over Medical Therapy in Stable Patients

Patients with stable coronary artery disease (CAD) today do no better with stents than with medical therapy, according to a new meta-analysis published in the Archives of Internal Medicine. Kathleen Stergiopoulos and David Brown identified 8 trials with 7,229 patients comparing stents to medical therapy in which stents were used in the majority of PCI cases. ”By limiting the analysis to studies in which stent implantation was the predominant form of PCI,” they explained, their meta-analysis “compares contemporary versions of PCI and medical therapy. The exclusion of studies using balloon angioplasty as the primary form of PCI shifted the years of enrollment forward by almost a decade during which time optimal medical therapy evolved to the current regimen that includes aspirin, β-blockers, ACE-inhibitors (or angiotensin receptor blockers) and statins.”

After a mean followup of 4.3 years, there were no significant differences between the stent and medical therapy groups:

  • Death: 8.9% for PCI versus 9.1% for medical therapy (OR 0.98, CI 0.84-1.16)
  • Nonfatal MI: 8.9% versus 8.1% (OR 1.12,CI 0.93-1.34)
  • Unplanned revascularization: 21.4% versus 30.7% (OR 0.78, CI 0.57-1.06)
  • Persistent angina: 29% versus 33% (OR 0.80; CI 0.60-1.05)

The authors write that their study “suggests that up to 76% of patients with stable CAD can avoid PCI altogether if treated with optimal medical therapy, resulting in a lifetime savings of approximately $9450 per patient in health care costs.”

In an accompanying editorial, William Boden writes that “the inescapable fact is that it is increasingly harder to justify use of PCI solely for angina relief in such patients — especially as an initial approach to management, and if medical therapy has not been first instituted (or if efforts to optimize pharmacologic treatment in those treated initially medically are not undertaken).”

Boden responds to the failure of clinical trials like BARI-2D and his own COURAGE trial to effect change in clinical practice:

While physicians outwardly worship at the altar of evidence-based medicine, in reality, we more often tend to practice selective evidence-based medicine by adopting and embracing those trials and studies with results that reinforce our existing clinical practice preferences or biases, while we ignore or disdain the results of studies with results that are unpopular, conflict with our existing clinical practice beliefs, or collide with the conventional wisdom.

Archives editor Rita Redberg places the study in the journal’s “Less Is More” category and writes that, despite the evidence, “fewer than half of Americans with stable CAD who undergo stent placement have received medical therapy first.”

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6 Responses to “Meta-Analysis Finds No Advantages for PCI Over Medical Therapy in Stable Patients”

  1. Joel Wolkowicz, MDCM says:
    February 27, 2012 at 8:36 pm

    Congratulations again to Dr. Boden for pointing out that the Emporer has no clothes.

  2. William L Blanchet, MD says:
    February 27, 2012 at 10:13 pm

    To take it a step further, how can we begin to justify the 10 million nuclear stress tests performed every year in this country when a positive outcome of the stress test could lead to a stent for which there is no therapeutic benefit.

    The lack of efficacy of revascularization should result in a discontinuation of searching for obstruction. At the same time, traditional risk factors fail to identify coronary disease accurately, this is especially true in women.

    As we abandon stress imaging and revascularization, I strongly encourage clinicians to consider increasing the use of atherosclerosis imaging in the form of coronary calcium imaging to identify those at risk and appropriately initiate medical therapy to prevent symptomatic disease.

    • Fabio Alban, MD says:
      February 29, 2012 at 7:52 am

      I believe you’re right in general, William, but i would wait until ISCHEMIA trial to be so categorical about it. Maybe someone with a high burden of ischemic area (>10%)still benefit from revascularization, then justifyng the nuclear test (I guess courage nuclear part point to this way, but just a hyphotesis).

  3. Anil Virmani, MD, DRM says:
    February 28, 2012 at 8:03 am

    Again the stress has been on optimum medical therapy for stable angina patients, but the fact remains that vested interests and an unknown fear drive these patients for revascularization procedures, despite overwhelming evidence of no extra benefit at more the cost. Its high time that the patients should be educated properly rather than leaving the decision to interventional cardiologists.

  4. Michael Mirochna, MD, BS says:
    March 1, 2012 at 7:29 pm

    Did we just fix healthcare reform and the deficit all at once? What will patients do when they are told they don’t need all of this expensive intervention and testing? Will doctors not tell them? Will patients lose all faith in the system? Will they pay out of pocket? Will they wonder what we are doing? Will they run to dr. Oz and Oprah plus minus quackery?

  5. David Nash, BA MD says:
    March 2, 2012 at 7:18 pm

    THE VALUE OF AGGRESIVE MEDICAL THERAPY FOR STABLE ANGINA HAS BEEN KNOW FOR OVER 5 YEARS. I PUBLISHED SUCH A FINDING IN THE aM J cARDIOLOGY IN2006.
    WE COULD SAVE A GREAT DEAL OF MONEY FROM PROCEDURAL HEALTH CARE BY FUNDING MINIMAL EXERCISE AND DIETARY THERAPY COSTS.
    DAVID NASH CLINICAL PROFESSOR OF MEDICINE