Expert Review: Valve Disease

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Prevention of Spontaneous Myocardial Infarction in Subjects With Stable Ischemic Heart Disease

Background 

CAD is the leading cause of death worldwide, contributing to over 7.2 million deaths  annually. Early revascularization has been well validated to show a reduction in cardiovascular events in the management of ST segment elevation MI1-3. In addition, revascularisation has been shown to improve cardiovascular outcomes in the management of non-ST segment elevation MI and unstable angina4,5. However, the optimal treatment strategy of nonacute CAD, manifest clinically as stable angina, is not well defined. Current guidelines for the management of stable angina emphasise risk factor modification, namely smoking cessation, exercise, diabetes mellitus management, lipid lowering, antianginal, and antihypertensive therapies6,7. Several trials, reviews and meta-analyses have been conducted to determine the role of PCI in patients with stable CAD, with some suggesting a greater relief of angina symptoms (oddsratio, 1.69; 95% CI, 1.24-2.30)8,9, and others showing no improvement in death, MI, or needfor subsequent revascularization using the invasive strategy10.

 

Knowledge Gap

The frequency of procedural MI varies depending on the population studied, the biomarker tested, and the threshold definition used, with frequency ranging up to 50%11.  However, its prognostic significance, especially in the setting of CAD is controversial.

 

 

Aim of the Study

The objective of the present study was to evaluate the association of PCI compared with OMT alone with various types of MI in patients with stable ischemic heart disease: spontaneous nonprocedural MI, procedural MI, and all MI, including procedural MI.

 

Methods

The authors of this article included 12 randomized clinical trials with 37 548 patients from an exhaustive search for randomized clinical trials on PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) comparing PCI with OMT for stable ischemic heart disease and reporting MI outcomes.

 

Results

The risk of spontaneous nonprocedural MI showed a statistically significant 24% relative reduction (RR=0.76; 95% confidence interval [CI], 0.58–0.99) (absolute reduction of 3.62 per 1000 patient-years) at the risk of a 317% relative increase (RR=4.17; 95% CI, 2.53–6.88) (absolute increase of 3.59 per 1000 patient-years) in the risk of procedural MI with PCI compared with OMT alone, with no difference in the risk of all MI (event rate, 18.28 versus 18.31 per 1000 patient-years) (RR=0.96; 95% CI, 0.74–1.21).

 

Conclusion

PCI compared with OMT reduced spontaneous MI at the risk of procedural MI without any difference in all MI. Consistent with prior studies showing that spontaneous MI but not procedural MI is related to subsequent mortality, in the present report the point estimate for reduced mortality with PCI compared with OMT paralleled the prevention of spontaneous MI with PCI. Further studies are needed to determine whether these associations are causal.

 

Clinical Impact 

The present report showed that there is no difference in the overall risk of MI between PCI and OMT alone. The higher risk of spontaneous MI with OMT should be balanced with the risk of procedural MI conferred by PCI.

Prospective trials are needed to determine whether the associations identified in the present meta-analysis are confirmed. If the results reported by Bangalore et al. with clinically significant prognostic differences between peri-procedural and spontaneous MI are confirmed in future studies, this will have important implications for routine clinical practice.

 

Corresponding author from original paper

Dr. Sripal Bangalore, MD, MHA. Cardiovascular Clinical Research Center, New York University School of Medicine, Leon H. Charney. Division of Cardiology, New York, NY 10016. E-mail sripalbangalore@gmail.com


References:

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8. Bucher HC, Hengstler P, Schindler C, Guyatt GH. Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials. BMJ. 2000;321:73–77.

 

9. Wijeysundera HC, Nallamothu BK, Krumholz HM, Tu JV, Ko DT. Metaanalysis: effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med. 2010;152:370–379.

 

10.-Katritsis DG, Ioannidis JP. Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis. Circulation. 2005;111:2906–2912.

 

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Citation: Circulation. 2013;127:769-781

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