Skip to main content

Advertisement

SpringerLink
Log in

Effect of Percutaneous Coronary Intervention on Survival in Patients with Stable Ischemic Heart Disease

  • Ischemic Heart Disease (D Mukherjee, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This study aims to determine if percutaneous coronary intervention (PCI) does improve survival in stable ischemic heart disease (SIHD).

Recent Findings

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial will evaluate patients with moderate to severe ischemia and will be the largest randomized trial of an initial management strategy of coronary revascularization (percutaneous or surgical) versus optimal medical therapy alone for SIHD. Although the ISCHEMIA trial may show a benefit with upfront coronary revascularization in this high-risk population, cardiac events after PCI are largely caused by plaque rupture in segments outside of the original stented segment. Furthermore, given the robust data from prior randomized trials, which showed no survival benefit with PCI, and the likelihood that the highest risk patients in ISCHEMIA will be treated with surgery, it is unlikely that the ISCHEMIA trial will show a survival benefit particular to PCI.

Recent Findings

Although PCI relieves symptoms, the evidence base indicates that it does not prolong survival in SIHD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: •Of importance ••Of major importance

  1. Boden W, et al. Optimal medical therapy with or without PCI for stables coronary disease. N Engl J Med. 2007;356(15):1503–16.

    Article  CAS  PubMed  Google Scholar 

  2. The BARI 2D Study Group. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360(2503):2515.

    Google Scholar 

  3. •• Sedlis SP, et al. Effect of PCI on long-Tem survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373:1937–46. Long-term follow-up of the COURAGE trial (0-15 year, median 11.9 years) with total of 561 deaths found no difference in survival between OMT and PCI groups.

    Article  CAS  PubMed  Google Scholar 

  4. Shaw L, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008;117(10):1283–91.

    Article  PubMed  Google Scholar 

  5. Hachamovitch R, et al. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation. 2003;107:2900–7.

    Article  PubMed  Google Scholar 

  6. www.ischemiatrial.org. Last Accessed 8/17/2016

  7. O’Brien KD, et al. Comparison of apolipoprotein and proteoglycan deposits in human coronary atheroslerotic plaques: colocalization of biglycan with apolipoproteins. Circulation. 1998;98:519–27.

    Article  PubMed  Google Scholar 

  8. Virmani R, et al. Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Bio. 2000;20(5):1262.

    Article  CAS  Google Scholar 

  9. Crisby M, et al. Pravastatin treatment increases collagen content and decreases lipid content, inflammation, metalloproteinases, and cell death in human carotid plaques: implications for plaque stabilization. Circulation. 2001;103(7):926.

    Article  CAS  PubMed  Google Scholar 

  10. Stone GW, et al. Prospect study: a prospective natural-history study of coronary atherosclerosis. PROSPECT investigator. N Engl J Med. 2011;364(3):226.

    Article  CAS  PubMed  Google Scholar 

  11. Ambrose JA, et al. Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol. 1988;12(1):56–62.

    Article  CAS  PubMed  Google Scholar 

  12. Little WC, et al. Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease? Circulation. 1988;78(5 Pt 1):1157–66.

    Article  CAS  PubMed  Google Scholar 

  13. Mancini GBJ, et al. Angiographic disease progression and residual risk of cardiovascular events while on optimal medical therapy: observations from the COURAGE trial. Circ Card Int. 2011;4(6):545–52.

    Google Scholar 

  14. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven year survival in the veterans administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med. 1984;311:1333–9.

    Article  Google Scholar 

  15. European Coronary Surgery Study Group. Long-term results of a prospective randomised trial of coronary artery bypass surgery in stable angina pectoris. Lancet. 982;1173–1180

  16. Chaitman BR, et al. Coronary Artery Surgery Study (CASS): comparability of 10 year survival in randomized and randomizable patients. J Am Coll Cardiol. 1990;16:1071–8.

    Article  CAS  PubMed  Google Scholar 

  17. CASS Principal Investigators and Their Associates. Coronary Artery Surgery (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation. 1983;68:939–50.

    Article  Google Scholar 

  18. Rihal CS, Raco DL, Gersh BJ, Yusuf S. Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations. Circulation 2003;108:2439–2445.

  19. • Garcia S, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol. 2013;62(16):1421–31. Meta-analysis of 35 studies including 89,883 patients which compares complete revascularization versus incomplete revascularization by CABG or PCI in patients with multivessel CAD. Approximately half of the two groups received complete revascularization and the other half received incomplete revascularization. Most patients that were revascularized by CABG achieved complete versus those that were revascularized by PCI.

    Article  PubMed  Google Scholar 

  20. Hannan EL, et al. Drug-eluting stents vs coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med. 2008;358:331–4.

    Article  CAS  PubMed  Google Scholar 

  21. Weintraub WS, et al. Comparative effectiveness of revascularization strategies. N Engl J Med. 2012;366:1467–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. BARI investigators. The final 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol. 2007;49(15):1600–6.

    Article  Google Scholar 

  23. Farkouh ME, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.

    Article  CAS  PubMed  Google Scholar 

  24. • Mohr FW, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5 year follow-up of the randomized, clinical SYNTAX trial. Lancet. 2013;381(9867):629–38. Report of the 5 year follow-up of the SYNTAX trial, compared CABG with PCI for the treatment in patients with left main coronary disease or three vessel disease. This multicentered trial of 1800 patients randomly assigned patients to either CABG group or PCI group. After 5 year follow it was found that major adverse cardiac and cerebrovascular events were lower in the CABG versus the PCI group (26.9% vs 37.3%). This study determined that CABG should remain the standard of care in patients with complex lesions, determined by high or intermediate SYNTAX scores. For patients with low SYNTAX scores PCI was determined to be an acceptable alternative.

    Article  PubMed  Google Scholar 

  25. • Sipahi I, et al. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease. JAMA Intern Med. 2014;174(2):223–30. Meta-analysis of 6 randomized trials totaling 6055 patients set out to determine the comparative effects of CABG vs PCI on long term mortality and morbidity in patient with multivessel disease. This study concluded that in patients with multivessel disease, CABG compared to PCI results in a reduction in long-term mortality and myocardial infarction.

    Article  PubMed  Google Scholar 

  26. RITA-2 participants. Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. Lancet. 1997;350(9076):461–8.

    Article  Google Scholar 

  27. Folland ED, et al. Percuatneous transluminal coronary angioplasty versus medical therapy for stable angina pectoris: outcomes for patients with double-vessel versus single-vessel coronary artery disease in a Veterans Affairs Cooperative randomized trial. J Am Coll Cardiol. 1997;29(7):1505–11.

    Article  CAS  PubMed  Google Scholar 

  28. Pitt B, et al. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. N Engl J Med. 1999;341:70–6.

    Article  CAS  PubMed  Google Scholar 

  29. Henderson RA, et al. Second Randomized Intervention Treatment of Angina (RITA-2) trial participants. Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy. J Am Coll Cardiol. 2003;42(7):1161–70.

    Article  PubMed  Google Scholar 

  30. Hartigan PM, Giacomini JC, Folland ED, Parisi AF. Two to three year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Am J Cardiol. 1998;82(12):1445–50.

    Article  CAS  PubMed  Google Scholar 

  31. Tonino PA, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360:213–24.

    Article  CAS  PubMed  Google Scholar 

  32. Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary disease; 2 year follow up of the FAME study. J Am Coll Cardiol. 2010;56:177–84.

    Article  PubMed  Google Scholar 

  33. De Bruyne B, Pijls NHJ, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991–1001.

  34. Sedlis SP, et al. Percutaneous coronary intervention: FAME is lasting. Lancet. 2015;386(10006):1806–7.

    Article  PubMed  Google Scholar 

  35. Bangalore S, et al. Short and long term outcomes with drug-eluting and bare metal coronary stents: a mixed treatment comparison analysis of 117 762 patients years of follow up from randomized trials. Circulation. 2012;125(23):2873.

    Article  CAS  PubMed  Google Scholar 

  36. Applegate RJ, et al. Long term ( three year) safety and efficacy of everolimus-eluting stents compared to paclitaxel- eluting stents ( from the SPIRIT III Trial). Am J Cardiol. 2011;107(6):833–40.

    Article  CAS  PubMed  Google Scholar 

  37. • Windecker S, Stortecky S, Juni P. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ. 2014;348:3859. Meta-analysis of 100 trials totaling 93,553 which compares whether revascularization improves prognosis compared to medical treatment among patients with stable coronary artery disease. Among the patients with stable CAD, it was found that CABG reduces the risk of death, MI and revascularization compared to medical treatment.

    Article  Google Scholar 

  38. Bonaa KH, Mannsverk J, Wiseth, R. et al, Drug-eluting or bare-metal stents for coronary artery disease. N Engl J Med. 2016;375:1242–1252.

  39. M Emond, M.B Mock, K.B Davis, et al. Long-term survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry. Circulation. 1994;90:2645–2657

  40. Takaro T, Peduzzi P, Detre KM, et al. Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation. 1982;66:14–22.

  41. Chaitman BR, et al. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol. 1981;48(4):765.

    Article  CAS  PubMed  Google Scholar 

  42. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines, and the American Collegge of Physicians, American Association for Thoracic Surgery, Preventative Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012; 126:e354–471.

  43. •• Gada H, et al. Meta-analysis of trials on mortality after percutaneous coronary intervention compared with medical therapy in patients with stable coronary heart disease and objective evidence of myocardial ischemia. Am J Cardiol. 2015;115(9):1194–9. Meta-analysis of 3 randomized clinical trials totaling 1,557 patients comparing PCI with OMT in patients with documented myocardial ischemia set out to find out if those with objective ischemia would benefit from PCI versus OMT alone. PCI with OMT compared to OMT alone was associated with a reduction in mortality in RCTs that enrolled patients with objective evidence of ischemia using noninvasive stress imaging or abnormal FFR. In PCI plus MT versus MT alone 3.0% versus 5.9% of the patients died. In the analysis of pooled HR, a significant reduction in all-cause mortality was 0.52.

    Article  PubMed  Google Scholar 

  44. Velazquez EJ, et al. Long-term survival of patients with ischemic cardiomyopathy treated by coronary artery bypass grafting versus medical therapy. Ann Thorac Surg. 2012;93:523–30.

    Article  PubMed  PubMed Central  Google Scholar 

  45. O’Connor CM, et al. Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol. 2002;90:101–7.

    Article  PubMed  Google Scholar 

  46. Velazquez EJ, for the STICH Investigators, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364:1607–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Velasquez EJ, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016;374:1511–20.

    Article  Google Scholar 

  48. Shaw LJ, et al. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention. Am Heart J. 2012;164:243–50.

    Article  PubMed  Google Scholar 

  49. Moroi M, et al. Coronary revascularization does not decrease cardiac events in patients with stable ischemic heart disease but might do in those who showed moderate to severe ischemia. Int J Cardiol. 2012;158:246–52.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Binita Shah was supported in part by the Biomedical Laboratory Research & Development Service of the VA Office of Research and Development (I01BX007080).

Author information

Authors and Affiliations

  1. Department of Medicine Division of Cardiology New York VA Healthcare Network and New York University School of Medicine, 423 East 23rd Street, New York, NY, 10010, USA

    Francisco Ujueta, Ephraim N. Weiss, Binita Shah & Steven P. Sedlis

Authors
  1. Francisco Ujueta
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ephraim N. Weiss
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Binita Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Steven P. Sedlis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Steven P. Sedlis.

Ethics declarations

Conflict of Interest

Francisco Ujueta, Ephraim N. Weiss, Binita Shah, and Steven P. Sedlis declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Ischemic Heart Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ujueta, F., Weiss, E.N., Shah, B. et al. Effect of Percutaneous Coronary Intervention on Survival in Patients with Stable Ischemic Heart Disease. Curr Cardiol Rep 19, 17 (2017). https://doi.org/10.1007/s11886-017-0821-6

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-017-0821-6

Keywords

Search

Navigation