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Percutaneous Coronary Intervention for Chronic Stable Angina

A Reassessment

David R. Holmes, Jr, MD, FACC^_*,_*, Bernard J. Gersh, MB, ChB, DPhil, FACC^_*,1, Patrick Whitlow, MD, FACC^,2, Spencer B. King, III, MD, MACC^,3, James T. Dove, MD, FACC

^_* Department of Cardiology, Division of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, Minnesota
The Cleveland Clinic, Cleveland, Ohio
Fuqua Heart Center, Atlanta, Georgia
Prairie Cardiovascular Consultants, Southern Illinois University School of Medicine, Springfield, Illinois.

^_* Reprint requests and correspondence: Dr. David R. Holmes, Jr., Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. (Email: holmes.david{at}mayo.edu).

As it approaches its fourth decade, percutaneous coronary intervention (PCI) is now the most widely used revascularization strategy around the world and has been tested in multiple clinical scenarios against both medical and surgical therapies. For each patient group and clinical scenario setting, the goals of therapy must be specifically defined and clearly understood as an integral component of the process of selecting the optimal strategy for the individual patient. In patients with chronic stable, often mild angina, the major achievable goals of PCI are to affect symptoms, either by decreasing them or preventing them, reduce the need for subsequent procedures, and relieve ischemia. Achievement of these goals has been documented in multiple randomized trials of PCI versus medical therapy. In these trials of patients with stable coronary artery disease (CAD), however, no reduction in death and myocardial infarction has been observed, and these limitations of PCI in this clinical setting need to be emphasized. Given the typically diffuse nature of CAD and the fact that PCI only treats a segment within a coronary artery, this is not surprising. Although optimal medical therapy forms the cornerstone of management for any patient with CAD, among stable patients who do fail medical therapy, percutaneous coronary revascularization plays a well-documented significant role in improving symptoms and preventing the subsequent need for revascularization. The appropriate utilization rates of PCI in patients with chronic stable angina and preserved left ventricular function should lead to more cost-effective care of patients with stable CAD.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   ACS = acute coronary syndromes   BMS = bare-metal stent(s)   CABG = coronary artery bypass grafting   CAD = coronary artery disease   DES = drug-eluting stent(s)   FDA = Food and Drug Administration   LV = left ventricular   MI = myocardial infarction   PCI = percutaneous coronary intervention   PTCA = percutaneous transluminal coronary angioplasty   STEMI = ST-segment elevation myocardial infarction