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What constitutes an appropriate empirical trial of antianginal therapy in patients with stable angina before referral for revascularisation?

2022; Elsevier BV; Volume: 399; Issue: 10325 Linguagem: Inglês

10.1016/s0140-6736(21)02045-6

1474-547X

William E. Boden, Juan Carlos Kaski, Rasha Al‐Lamee, William S. Weintraub,

Cardiovascular Function and Risk Factors

Randomised clinical trials conducted over two decades, including the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial in patients with extensive coronary artery disease and moderate-to-severe ischaemia, and a contemporary meta-analysis comparing optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) for the treatment of chronic coronary syndromes, have not found any difference in deaths or rate of non-fatal myocardial infarction. 1 Boden WE O'Rourke RA Teo KK et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007; 356: 1503-1516 Crossref PubMed Scopus (3537) Google Scholar , 2 Frye RL August P et al. BARI 2D Study GroupA randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009; 360: 2503-2515 Crossref PubMed Scopus (1482) Google Scholar , 3 Soares A Boden WE Hueb W et al. Death and myocardial infarction following initial revascularization versus optimal medical therapy in chronic coronary syndromes with myocardial ischemia: a systematic review and meta-analysis of contemporary randomized controlled trials. J Am Heart Assoc. 2021; 10e019114 Crossref PubMed Scopus (4) Google Scholar , 4 Maron DJ Hochman JS Reynolds HR et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020; 382: 1395-1407 Crossref PubMed Scopus (758) Google Scholar Although, in unblinded trials, PCI plus OMT compared with OMT alone reduces angina and improves quality of life, uncertainty persists about when an initially conservative strategy should give way to revascularisation for persistent angina. 5 Weintraub WS Spertus JA Kolm P et al. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008; 359: 677-687 Crossref PubMed Scopus (529) Google Scholar , 6 Spertus JA Jones PG Maron DJ et al. Health-status outcomes with invasive or conservative care in coronary disease. N Engl J Med. 2020; 382: 1408-1419 Crossref PubMed Scopus (151) Google Scholar Many cardiologists believe, when confronted with high-grade, multivessel coronary artery disease or moderate-to-severe ischaemia in patients with chronic coronary syndromes, that deferral of PCI might prove fatal. Yet, in the ISCHEMIA trial, there were only 66 sudden cardiac deaths among 5179 patients (1·3% incidence) during a median 3·2-year follow-up period, with no increase in deaths in conservatively managed patients, 4 Maron DJ Hochman JS Reynolds HR et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020; 382: 1395-1407 Crossref PubMed Scopus (758) Google Scholar suggesting that there is no need to rush to revascularisation before first undertaking adequate treatment of the symptoms. Given the consistency of these overall findings, both European and US practice guidelines currently advocate OMT as the initial management strategy, with revascularisation reserved largely for when treatment of symptoms fails. 7 Knuuti J Wijns W Saraste A et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020; 41: 407-477 Crossref PubMed Scopus (1943) Google Scholar , 8 Fihn SD Blankenship JC Alexander KP et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014; 64: 1929-1949 Crossref PubMed Scopus (522) Google Scholar However, it is not clear what exactly constitutes optimal pharmacotherapy or when one should determine that OMT for symptom relief has supposedly failed.