Journal of General Internal Medicine

, Volume 29, Issue 7, pp 1031–1039

Comparative-Effectiveness of Revascularization Versus Routine Medical Therapy for Stable Ischemic Heart Disease: A Population-Based Study

  • Harindra C. Wijeysundera
  • Maria C. Bennell
  • Feng Qiu
  • Dennis T. Ko
  • Jack V. Tu
  • Duminda N. Wijeysundera
  • Peter C. Austin
Original Research



Randomized studies have shown optimal medical therapy to be as efficacious as revascularization in stable ischemic heart disease (IHD). It is not known if these efficacy results are reflected by real-world effectiveness.


To evaluate the comparative effectiveness of routine medical therapy versus revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in stable IHD.


Observational cohort study.


Stable IHD patients from 1 October 2008 to 30 September 2011, identified using a Registry of all angiography patients in Ontario, Canada.


Revascularization, defined as PCI/CABG within 90 days after index angiography.


Death, myocardial infarction (MI) or repeat PCI/CABG. Revascularization was compared to medical therapy using a) multivariable Cox-proportional hazard models with therapy strategy treated as a time-varying covariate; and b) a propensity score matched analysis. Post-angiography medication use was determined.


We identified 39,131 stable IHD patients, of whom 15,139 were treated medically, and 23,992 were revascularized (PCI = 15,604; CABG = 8,388). Mean follow-up was 2.5 years. Revascularization was associated with fewer deaths (HR 0.76; 95 % CI 0.68–0.84; p < 0.001) ,MIs (HR 0.78; 95 % CI 0.72–0.85; p < 0.001) and repeat PCI/CABG (HR 0.59; 95 % CI 0.50–0.70; p < 0.001) than medical therapy. In the propensity-matched analysis of 12,362 well–matched pairs of revascularized and medical therapy patients, fewer deaths (8.6 % vs 12.7 %; HR 0.75; 95 % CI 0.69–0.81; p < 0.001) , MIs (11.7 % vs 14.4 %; HR 0.84; 95 % CI 0.77–0.93 p < 0.001) and repeat PCI/CABG ( 17.4 % vs 24.1 %;HR 0.67; 95 % 0.63–0.71; p < 0.001) occurred in revascularized patients, over the 4.1 years of follow-up.

The revascularization patients had higher uptake of clopidogrel (70.3 % vs 27.2 %; p < 0.001), β-blockers (78.2 % vs 76.7 %; p = 0.010), and statins (94.7 % vs 91.5 %, p < 0.001) in the 1-year post-angiogram.


Stable IHD patients treated with revascularization had improved risk-adjusted outcomes in clinical practice, potentially due to under-treatment of medical therapy patients.


stable ischemic heart disease angioplasty medical therapy coronary artery bypass grafting comparative effectiveness 

Supplementary material

11606_2014_2813_MOESM1_ESM.pdf (513 kb)
ESM 1(PDF 513 kb)


  1. 1.
    Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, et al. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol. 2007;50(23):2264–74.PubMedCrossRefGoogle Scholar
  2. 2.
    Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–16.PubMedCrossRefGoogle Scholar
  3. 3.
    Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, Nallamothu BK, Kent DM. Percutaneous coronary interventions for non-acute coronary artery disease: a quantitative 20-year synopsis and a network meta-analysis. Lancet. 2009;373(9667):911–8.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Group BDS, Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360(24):2503–15.CrossRefGoogle Scholar
  5. 5.
    Kereiakes DJ, Teirstein PS, Sarembock IJ, Holmes DR Jr, Krucoff MW, O’Neill WW, et al. The Truth and Consequences of the COURAGE Trial. J Am Coll Cardiol. 2007;50(16):1598–603.PubMedCrossRefGoogle Scholar
  6. 6.
    Cardiac Care Network of Ontario. []. Accessed 6 February 2013.
  7. 7.
    Cardiac Care Network (CCN) Annual Report 2010/2011. 2011.Google Scholar
  8. 8.
    Tu JV, Ko DT, Guo H, Richards JA, Walton N, Natarajan MK, et al. Determinants of variations in coronary revascularization practices. CMAJ. 2011.Google Scholar
  9. 9.
    Levy AR, O’Brien BJ, Sellors C, Grootendorst P, Willison D. Coding accuracy of administrative drug claims in the Ontario Drug Benefit database. Can J Clin Pharmacol. 2003;10(2):67–71.PubMedGoogle Scholar
  10. 10.
    Ko DT, Newman AM, Alter DA, Austin PC, Chiu M, Cox JL, et al. Secular trends in acute coronary syndrome hospitalization from 1994 to 2005. Can J Cardiol. 2010;26(3):129–34.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Levesque LE, Hanley JA, Kezouh A, Suissa S. Problem of immortal time bias in cohort studies: example using statins for preventing progression of diabetes. BMJ. 2010;340:b5087.PubMedCrossRefGoogle Scholar
  12. 12.
    Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Multivariate Behav Res. 2011;46(3):399–424.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat. 2010.Google Scholar
  14. 14.
    Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28(25):3083–107.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Austin PC. Comparing paired vs non-paired statistical methods of analyses when making inferences about absolute risk reductions in propensity-score matched samples. Stat Med. 2011;30(11):1292–301.PubMedCentralPubMedGoogle Scholar
  16. 16.
    Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol. 2003;41(1):56–61.PubMedCrossRefGoogle Scholar
  17. 17.
    Wijeysundera HC, Machado M, Farahati F, Wang X, Witteman W, van der Velde G, et al. Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994–2005. JAMA. 2010;303(18):1841–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Wijeysundera HC, Mitsakakis N, Witteman W, Paulden M, van der Velde G, Tu JV, et al. Achieving quality indicator benchmarks and potential impact on coronary heart disease mortality. Can J Cardiol. 2011;27(6):756–62.PubMedCrossRefGoogle Scholar
  19. 19.
    Borden WB, Redberg RF, Mushlin AI, Dai D, Kaltenbach LA, Spertus JA. Patterns and intensity of medical therapy in patients undergoing percutaneous coronary intervention. JAMA. 2011;305(18):1882–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706–17.PubMedCrossRefGoogle Scholar
  21. 21.
    Opie LH, Commerford PJ, Gersh BJ. Controversies in stable coronary artery disease. [Review] [114 refs]. Lancet. 2006;367(9504):69–78.PubMedCrossRefGoogle Scholar
  22. 22.
    Steinberg BA, Steg PG, Bhatt DL, Fonarow GC, Zeymer U, Cannon CP, et al. Comparisons of guideline-recommended therapies in patients with documented coronary artery disease having percutaneous coronary intervention versus coronary artery bypass grafting versus medical therapy only (from the REACH International Registry). Am J Cardiol. 2007;99(9):1212–5.PubMedCrossRefGoogle Scholar
  23. 23.
    American College of Cardiology, American Heart Association, Physician Consortium for Performance ImprovementClinical Performance Measures: Chronic Stable Coronary Artery Disease. . 2003.Google Scholar
  24. 24.
    Hannan EL, Samadashvili Z, Cozzens K, Walford G, Jacobs AK, Holmes DR Jr, et al. Comparative outcomes for patients who do and do not undergo percutaneous coronary intervention for stable coronary artery disease in New York. Circulation. 2012;125(15):1870–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Muhlbaier LH, Pryor DB, Rankin JS, Smith LR, Mark DB, Jones RH, et al. Observational comparison of event-free survival with medical and surgical therapy in patients with coronary artery disease. 20 years of follow-up. Circulation. 1992;86(5 Suppl):II198–204.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Harindra C. Wijeysundera
    • 1
    • 2
    • 3
    • 4
  • Maria C. Bennell
    • 1
  • Feng Qiu
    • 3
  • Dennis T. Ko
    • 1
    • 2
    • 3
  • Jack V. Tu
    • 1
    • 2
    • 3
  • Duminda N. Wijeysundera
    • 2
    • 3
    • 4
    • 5
  • Peter C. Austin
    • 3
  1. 1.Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
  2. 2.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  3. 3.Institute for Clinical Evaluative Sciences (ICES)TorontoCanada
  4. 4.Li Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada
  5. 5.Department of AnesthesiaToronto General Hospital and University of TorontoTorontoCanada

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