ANY ROLE OF PCI IN STABLE CAD?

Abstract

In our clinical practice we come across patients with all shades of angina: somewho respond to treatment and at times others with intractable symptoms withminimal response to anti-anginal therapy. These patients continue to experienceeffort-limiting angina in spite of the cocktail of anti-anginals. Once blockages aretaken care of with angioplasty, patients enjoy enhanced effort tolerance with relieffrom angina. Many patients after PCI remain symptom free during theirsubsequent course of life. Any instent restenosis or denovo blockages result inrecurrence of angina, which again, usually does not respond to combination ofanti-anginals and requires reintervention. In some patients a particular segmentkeeps on restenosing and resulting in angina with rapid, sustained and almostcomplete relief of angina after intervention. Our clinical experience encouragesand guides us to offer PCI as a one of first line treatments in patients with stableangina who have presenting complaints of angina, suboptimal response to antianginalsand have objective evidence of ischeamia as documented by exerciseECG or nuclear test. Lately any patient presenting with angina or ischemia wasconsidered for angiography and all significant lesions were treated withangioplasty. Should angiography followed by PCI be offered to all patients with allshades of angina? What is the role of anti anginal treatment? More importantly atwhat stage in symptomatology and chronology intervention should be offered?

The authors opine that their data support existing clinical practice guidelines, that PCI can be safely postponed in patients withstable CAD, even in those with extensive, multivessel involvement and inducible ischemia, provided that intensive, medicaltherapy is introduced and maintained. Hence it was suggested that as an initial management approach, optimal medicaltherapy without routine PCI can be used safely in the majority of patients with stable CAD. It must be realized that approximatelythirty percent of these patients may subsequently require revascularization for symptom control or for subsequent developmentof an acute coronary syndrome.

It may be safely concluded that both trials emphasize to treat patients as a whole and address symptoms rather than focusingonly on obstructive lesions. The approach to take all patients for angiography with any suspicion of angina has been seriouslyquestioned and proven to be incorrect. In all fairness, all patients should be given a fair trial of anti anginals and only those whodo not respond or have early positive test or have large myocardial area at jeopardy may be considered for further work up andintervention. This approach should be with clear understanding that it is not to improve mortality or reduce major adverse eventsbut to control symptoms in selected cases till we get more evidence.