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Optimal approach to symptomatic stable coronary artery disease

Chronic Ischaemic Heart Disease (IHD)

Optimal medical therapy is enough

(Pro: Dr. W Boden; Contra: Dr. A H Gershlick)

This topic involves a clinical setting we all face on an almost daily basis in cardiovascular medicine. Despite the available scientific evidence addressing the question, several questions have not yet been clearly answered.
The optimal approach to symptomatic stable CAD patients should include benefits on hard endpoints; i.e. survival improvement and reduction in myocardial infarction rates, in both the short- and long-term. Another component of the benefits of this approach includes quality of life parameters, such as angina relief rates, which should be addressed as an additional component, but not in isolation without taking into account clinically relevant endpoints. The totality of evidence prior to the COURAGE trial was underpowered to allow valid and reliable conclusion.
The COURAGE trial should not be considered as a definite study; however, it is highly informative for the clinical practice, suggesting that optimized medical treatment (OMT) in comparison to PCI+OMT are comparable without detected differences in hard endpoints.
Patients in the PCI group presented higher rates of angina relief. Probably, the COURAGE trial does not truly reflect the best practice with symptomatic stable CAD, the use of drug-eluting stents was low. However, randomized clinical trials, by their very nature, carry a different degree of selection bias. The ISCHEMIA trial, when finished, will shed additional light on this clinical setting, but until we have reliable, solid, robust and relatively unbiased data, we should pursue appropriate PCI indications.
In this particular population, clinical treatment (antiplatelets, beta blockers, ACE-inhibitors and statins) must be implemented, adherence ensured, and if symptoms persist, PCI would be indicated.

Proximal left anterior descending stenosis should be treated surgically

(Pro:  D Taggart; Contra: F J Neumann)
Another clinically important topic to be discussed in the Debate Session included the choice or preference between a percutaneous and a surgical approach for proximal LAD stenosis.
The objectives to be pursued in this comparison should include mortality (both cardiovascular and any cause) as well as myocardial infarction and stroke rates, as a composite endpoint. Surrogate endpoints, such as graft patency rates for CABG and restenosis rates for PCI, should be seen as promising. However, clinically relevant endpoint results are needed for a reliable comparison of efficacy and safety. The available evidence suggests that long-term survival rates are not statistically significant different.
Nonetheless, rates of new revascularization were higher in the PCI group. The clinical decision-making process should be conducted on an individual basis to choose the most appropriate strategy, either surgical or percutaneous, taking into account patient risk, operator experience, coronary anatomy, costs and patient preferences. New surgical techniques and new generation stents should be tested, by means of clinically relevant endpoints through well powered studies, in order to be incorporated into the clinical practice.



Session Title: Optimal approach to symptomatic stable coronary artery disease

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.