Skip to main content
SpringerLink
Log in

The State of Percutaneous Intervention in Stable Coronary Artery Disease

  • Coronary Heart Disease (S. Virani and S. Naderi, Section Editor)
  • Published:
Current Atherosclerosis Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review examines trials of percutaneous coronary intervention (PCI) compared with optimal medical therapy (OMT) in order to inform clinical decision-making regarding the role of PCI in stable ischemic heart disease (SIHD).

Recent Findings

Several large, randomized, controlled trials published in recent years suggest that OMT should be the initial treatment strategy for symptomatic SIHD, but there is a role for PCI in patients who continue to be symptomatic despite OMT. Additionally, using fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) techniques may help to identify physiologically significant lesions and may be useful in maximizing the benefit from PCI in SIHD.

Summary

Recent trials demonstrate PCI for the treatment of symptomatic SIHD does not reduce mortality compared with OMT but effectively relieves anginal symptoms. However, OMT continues to be the first-line therapy for SIHD but is significantly underutilized.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999;99:2829–48.

    Article  CAS  Google Scholar 

  2. Chan PS, Jones PG, Arnold SA, Spertus JA. Development and validation of a short version of the Seattle Angina Questionnaire. Circ Cardiovasc Qual Outcomes. 2014;7:640–7.

    Article  Google Scholar 

  3. Campeau L. Gradient of angina pectoris. Circulation. 1976;54(3):522–3.

    Article  CAS  Google Scholar 

  4. Bansilal S, Castellano JM, Garrido E, Wei HG, Freeman A, Spettell C, et al. Assessing the impact of medication adherence on long-term cardiovascular outcomes. JACC. 2016;68(8):789–801.

    Article  Google Scholar 

  5. •• Maron DJ, Hochman JS, Reynolds HR, et al. Initial invasive or conservative strategy for stable coronary disease. NEJM. 2020;382:1395–407 The ISCHEMIA trial demonstrates no significant difference in cardiovascular mortality between an initial invasive strategy and optimal medical therapy for stable ischemic heart disease.

    Article  Google Scholar 

  6. Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. NEJM. 2007;356:1503–16.

    Article  CAS  Google Scholar 

  7. • Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391:31–40 This trial reports no improvement in exercise time six weeks after PCI for stable ischemic heart disease when compared with medical therapy.

    Article  Google Scholar 

  8. •• Spertus JA, Jones PG, Maron DJ, et al. Health-status outcomes with invasive or conservative care in coronary disease. NEJM. 2020;382:1408–19 Ischemic symptoms improved significantly with an invasive strategy as compared with optimal medical therapy for patients in the ISCHEMIA trial.

    Article  Google Scholar 

  9. Sedlis SP, Hartigan PM, Teo KK, Maron DJ, Spertus JA, Mancini GB, et al. Effect of PCI on long-term survival in patients with stable ischemic heart disease. NEJM. 2015;373:1937–46.

    Article  CAS  Google Scholar 

  10. Maron DJ, Hochman JS, O’Brien SM, et al. International study of comparative health effectiveness with medical and invasive approaches (ISCHEMIA) trial: rationale and design. AHJ. 2018;201:124–35.

    Article  Google Scholar 

  11. Bech GJ, De Bruyne B, Pijls NH, et al. Fractional flow reserve to determine the appropriateness of angioplasty in moderate coronary stenosis: a randomized trial. Circulation. 2001;103(24):2928–34.

    Article  CAS  Google Scholar 

  12. Zimmermann FM, Ferrara A, Johnson NP, van Nunen LX, Escaned J, Albertsson P, et al. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. EHJ. 2015;36:3182–8.

    Article  Google Scholar 

  13. Tonino PAL, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. NEJM. 2009;360:213–24.

    Article  CAS  Google Scholar 

  14. van Nunen LX, Zimmerman FM, Tonino PA, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet. 2015;386:1853–60.

    Article  Google Scholar 

  15. • Fearon WF, Nishi T, De Bruyne B, et al. Clinical outcomes and cost-effectiveness of fractional flow reserve-guided percutaneous coronary intervention in patients with stable coronary artery disease. Circulation. 2018;137:480–7 The FAME 2 trial shows lower rates of MACE and anginal symptoms in patients with stable CAD and FFR ≤ 0.80 after PCI as compared with optimal medical therapy.

    Article  Google Scholar 

  16. Al-Lamee R, Howard JP, Shun-Shin MJ, et al. Fractional flow reserve and instantaneous wave-free ratio as predictors of the placebo-controlled response to percutaneous coronary intervention in stable single-vessel coronary artery disease. Circulation. 2018;138:1780–92.

    Article  Google Scholar 

  17. Davies JE, Sen S, Dehbi HM, al-Lamee R, Petraco R, Nijjer SS, et al. Use of the instantaneous wave-free ratio or fractional flow reserve in PCI. NEJM. 2017;376:1824–34.

    Article  Google Scholar 

  18. Al-Lamee RK, Shun-Shin MJ, Howard JP, et al. Dobutamine stress echocardiography ischemia as a predictor of the placebo-controlled efficacy of percutaneous coronary intervention in stable coronary artery disease. Circulation. 2019;140:1971–80.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Duke University Medical Center, 508 Fulton Street (111A), Durham, NC, 27705, USA

    Caitlin Drescher & Sunil V. Rao

  2. The Duke Clinical Research Institute, Durham, NC, USA

    Sunil V. Rao

Authors
  1. Caitlin Drescher
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sunil V. Rao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sunil V. Rao.

Ethics declarations

Conflict of Interest

Dr. Sunil Rao reports modest research funding to Duke University Health System from Bayer Inc, Svelte Inc., and Shockwave Medical Inc. for his roles as principal investigator or on steering committees. Dr. Rao is an interventional cardiologist.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Coronary Heart Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Drescher, C., Rao, S.V. The State of Percutaneous Intervention in Stable Coronary Artery Disease. Curr Atheroscler Rep 22, 42 (2020). https://doi.org/10.1007/s11883-020-00859-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11883-020-00859-3

Keywords

Search

Navigation