Advertisement

Current Cardiology Reports

, 19:11 | Cite as

Challenges with Evidence-Based Management of Stable Ischemic Heart Disease

  • Amit V. Patel
  • Sripal BangaloreEmail author
Ischemic Heart Disease (D Mukherjee, Section Editor)
  • 400 Downloads
Part of the following topical collections:
  1. Topical Collection on Ischemic Heart Disease

Abstract

Purpose of Review

Stable ischemic heart disease (SIHD) is a highly prevalent condition associated with increased costs, morbidity, and mortality. Management goals of SIHD can broadly be thought of in terms of improving prognosis and/or improving symptoms. Treatment options include medical therapy as well as revascularization, either with percutaneous coronary intervention or coronary artery bypass grafting. Herein, we will review the current evidence base for treatment of SIHD as well as its challenges and discuss ongoing studies to help address some of these knowledge gaps.

Recent Findings

There has been no consistent reduction in death or myocardial infarction (MI) with revascularization vs. medical therapy in patients with SIHD in contemporary trials. Angina and quality of life have been shown to be relieved more rapidly with revascularization vs. optimal medical therapy; however, the durability of these results is uncertain. There have been challenges and limitations in several of the trials addressing the optimal treatment strategy for SIHD due to potential selection bias (due to knowledge of coronary anatomy prior to randomization), patient crossover, and advances in medical therapy and revascularization strategies since trial completion.

Summary

The challenges inherent to prior trials addressing the optimal management strategy for SIHD have impacted the generalizability of results to real-world cohorts. Until the results of additional ongoing trials are available, the decision for revascularization or medical therapy should be based on patients’ symptoms, weighing the risks and benefits of each approach, and patient preference.

Keywords

Challenges Management Stable ischemic heart disease 

Notes

Compliance with Ethical Standards

Conflict of Interest

Amit V. Patel declares that he has no conflict of interest.

Sripal Bangalore has received NIH grant support for the ISCHEMIA and ISCHEMIA-CKD trials. He is on the advisory board and gets research grant support from Abbott-Vascular.

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.

References

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

  1. 1.
    Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003.CrossRefPubMedGoogle Scholar
  2. 2.
    Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–322.CrossRefPubMedGoogle Scholar
  3. 3.
    Statistics. NCfH. Mortality multiple cause micro-data files, 2011. Public-use data file and documentation. NHLBI tabulations. [cited Accessed July 3, 2014.]. Available from: http://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm - Mortality_.
  4. 4.
    Hlatky MA, Rogers WJ, Johnstone I, et al. Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. Bypass Angioplasty Revascularization Investigation (BARI) Investigators. N Engl J Med. 1997;336(2):92–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Fihn SD, Gardin JM, Abrams J, et al. ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354–471.CrossRefPubMedGoogle Scholar
  6. 6.
    Yusuf S, Zucker D, Peduzzi P, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994;344(8922):563–70.CrossRefPubMedGoogle Scholar
  7. 7.
    Katritsis DG, Ioannidis JP. Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis. Circulation. 2005;111(22):2906–12.CrossRefPubMedGoogle Scholar
  8. 8.
    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(15):1503–16.CrossRefPubMedGoogle Scholar
  9. 9.
    •• Sedlis SP, Hartigan PM, Teo KK, et al. Effect of PCI on long-term survival in patients with stable ischemic heart disease. N Engl J Med. 2015;373(20):1937–46. This study provides long term follow up of the results from an important randomized strategy trial (COURAGE trial) demonstrating no difference in survival with follow up out to 15 years between PCI and OMT CrossRefPubMedGoogle Scholar
  10. 10.
    BARI 2D I, Frye RL, August P, 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
  11. 11.
    De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367(11):991–1001.CrossRefPubMedGoogle Scholar
  12. 12.
    De Bruyne B, Fearon WF, Pijls NH, et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med. 2014;371(13):1208–17.CrossRefPubMedGoogle Scholar
  13. 13.
    Pursnani S, Korley F, Gopaul R, et al. Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: a systematic review and meta-analysis of randomized clinical trials. Circulation Cardiovascular Interventions. 2012;5(4):476–90.CrossRefPubMedGoogle Scholar
  14. 14.
    Bangalore S, Pursnani S, Kumar S, et al. Percutaneous coronary intervention versus optimal medical therapy for prevention of spontaneous myocardial infarction in subjects with stable ischemic heart disease. Circulation. 2013;127(7):769–81.CrossRefPubMedGoogle Scholar
  15. 15.
    Bangalore S, Pencina MJ, Kleiman NS, et al. Prognostic implications of procedural vs spontaneous myocardial infarction: results from the Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry. Am Heart J. 2013;166(6):1027–34.CrossRefPubMedGoogle Scholar
  16. 16.
    Rogers WJ, Coggin CJ, Gersh BJ, et al. Ten-year follow-up of quality of life in patients randomized to receive medical therapy or coronary artery bypass graft surgery. The Coronary Artery Surgery Study (CASS). Circulation. 1990;82(5):1647–58.CrossRefPubMedGoogle Scholar
  17. 17.
    Coronary artery surgery study (CASS). A randomized trial of coronary artery bypass surgery. Circulation. 1983;68(5):939–50.CrossRefGoogle Scholar
  18. 18.
    Henderson RA, Pocock SJ, Clayton TC, et al. Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy. J Am Coll Cardiol. 2003;42(7):1161–70.CrossRefPubMedGoogle Scholar
  19. 19.
    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(7):677–87.CrossRefPubMedGoogle Scholar
  20. 20.
    Dagenais GR, Lu J, Faxon DP, et al. Effects of optimal medical treatment with or without coronary revascularization on angina and subsequent revascularizations in patients with type 2 diabetes mellitus and stable ischemic heart disease. Circulation. 2011;123(14):1492–500.CrossRefPubMedGoogle Scholar
  21. 21.
    Iqbal J, Zhang YJ, Holmes DR, et al. Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up. Circulation. 2015;131(14):1269–77.CrossRefPubMedGoogle Scholar
  22. 22.
    Bangalore S. Applicability of the COURAGE, BARI-2D, and FREEDOM trials to contemporary practice. J Am Coll Cardiol. 2016;68(10):996–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Bangalore S, Maron DJ, Hochman JS. Evidence-based management of stable ischemic heart disease: challenges and confusion. JAMA. 2015;314(18):1917–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Kosiborod M, Arnold SV, Spertus JA, et al. Evaluation of ranolazine in patients with type 2 diabetes mellitus and chronic stable angina: results from the TERISA randomized clinical trial (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina). J Am Coll Cardiol. 2013;61(20):2038–45.CrossRefPubMedGoogle Scholar
  25. 25.
    Zhang XL, Zhu QQ, Zhu L, et al. Safety and efficacy of anti-PCSK9 antibodies: a meta-analysis of 25 randomized, controlled trials. BMC Medicine. 2015;13:123.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Waksman R, Maya J, Angiolillo DJ, et al. Ticagrelor versus clopidogrel in black patients with stable coronary artery disease: prospective, randomized, open-label, multiple-dose. Crossover Pilot Study Circulation Cardiovascular Interventions. 2015;8(7):e002232.CrossRefPubMedGoogle Scholar
  27. 27.
    Hochholzer W, Amann M, Titov A, et al. Randomized comparison of different thienopyridine loading strategies in patients undergoing elective coronary intervention: the ExcelsiorLOAD Trial. JACC Cardiovascular Interventions. 2016;9(3):219–27.CrossRefPubMedGoogle Scholar
  28. 28.
    Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117–28.CrossRefPubMedGoogle Scholar
  29. 29.
    Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311–22.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372(25):2387–97.CrossRefPubMedGoogle Scholar
  31. 31.
    Group SR, Wright Jr JT, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16.CrossRefGoogle Scholar
  32. 32.
    Bangalore S, Toklu B, Amoroso N, et al. Bare metal stents, durable polymer drug eluting stents, and biodegradable polymer drug eluting stents for coronary artery disease: mixed treatment comparison meta-analysis. BMJ. 2013;347:f6625.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360(3):213–24.CrossRefPubMedGoogle Scholar
  34. 34.
    Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.CrossRefPubMedGoogle Scholar
  35. 35.
    Bangalore S. Complete revascularization in contemporary practice. Circulation Cardiovascular Interventions. 2013;6(1):5–7.CrossRefPubMedGoogle Scholar
  36. 36.
    •• Bangalore S, Guo Y, Samadashvili Z, et al. Everolimus-eluting stents or bypass surgery for multivessel coronary disease. N Engl J Med. 2015;372:1213–22. This study demonstrates that there is no difference in death between use of contemporary drug eluting stents and CABG CrossRefPubMedGoogle Scholar
  37. 37.
    Bangalore S, Guo Y, Samadashvili Z, et al. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation. 2016;133(22):2132–40.CrossRefPubMedGoogle Scholar
  38. 38.
    Serruys PW, Chevalier B, Dudek D, et al. A bioresorbable everolimus-eluting scaffold versus a metallic everolimus-eluting stent for ischaemic heart disease caused by de-novo native coronary artery lesions (ABSORB II): an interim 1-year analysis of clinical and procedural secondary outcomes from a randomised controlled trial. Lancet. 2015;385(9962):43–54.CrossRefPubMedGoogle Scholar
  39. 39.
    Locker C, Schaff HV, Daly RC, et al. Multiple arterial grafts improve survival with coronary artery bypass graft surgery versus conventional coronary artery bypass grafting compared with percutaneous coronary interventions. J Thorac Cardiovasc Surg. 2016;152(2):369–79. e4CrossRefPubMedGoogle Scholar
  40. 40.
    Mancini GB, Hartigan PM, Bates ER, et al. Prognostic importance of coronary anatomy and left ventricular ejection fraction despite optimal therapy: assessment of residual risk in the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation Trial. Am Heart J. 2013;166(3):481–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Hachamovitch R, Rozanski A, Hayes SW, et al. Predicting therapeutic benefit from myocardial revascularization procedures: are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary? Journal of Nuclear Cardiology Official Publication of the American Society of Nuclear Cardiology. 2006;13(6):768–78.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Cardiac Catheterization Laboratory, Cardiovascular Outcomes Group, Cardiovascular Clinical Research CenterNew York University School of MedicineNew YorkUSA
  2. 2.Division of CardiologyNew York University School of MedicineNew YorkUSA
  3. 3.New YorkUSA

Personalised recommendations