Advertisement

Advances in Management of Stable Coronary Artery Disease: the Role of Revascularization?

  • Konstantinos V. Voudris
  • Clifford J. KavinskyEmail author
Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • 108 Downloads
Part of the following topical collections:
  1. Topical Collection on Coronary Artery Disease

Abstract

Purpose of review

Coronary artery disease remains the most common cause of death worldwide. In patients with biomarker-positive acute coronary syndrome, the combination of guideline-directed medical therapy with routine revascularization is associated with improved outcomes. However, the role of routine revascularization in stable ischemic heart disease, in addition to medical therapy, remains a matter of debate. In this review, we aimed to describe the role of revascularization in stable ischemic heart disease.

Recent findings

Revascularization is indicated in patients with stable ischemic heart disease and progressive or refractory symptoms, despite medical management. When guided by ischemia presence, revascularization has failed to show survival benefit, compared with medical therapy alone in multiple clinical trials. On the other hand, revascularization guided by coronary lesion severity, assessed by FFR or iFR, has been shown to offer survival benefit and improvement in symptom severity. PCI-revascularization of unprotected left main disease is feasible with comparable to surgical approach outcomes.

Summary

Clinical decision to perform revascularization in stable ischemic heart disease necessitates a heart team approach, and no simple algorithm can guide this process. Further studies are required to assess the benefit of routine revascularization, in combination to medical therapy, in this population.

Keywords

Stable coronary artery disease Ischemic heart disease Revascularization Percutaneous coronary intervention Coronary artery bypass graft 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

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 and Recommended Reading

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

  1. 1.
    Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128.CrossRefGoogle Scholar
  2. 2.
    Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke Statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.CrossRefGoogle Scholar
  3. 3.
    Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388–98.CrossRefGoogle Scholar
  4. 4.
    Bangalore S, Gupta N, Genereux P, Guo Y, Pancholy S, Feit F. Trend in percutaneous coronary intervention volume following the COURAGE and BARI-2D trials: insight from over 8.1 million percutaneous coronary interventions. Int J Cardiol. 2015;183:6–10.CrossRefGoogle Scholar
  5. 5.
    Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13–20.CrossRefGoogle Scholar
  6. 6.
    Mehta SR, Cannon CP, Fox KA, Wallentin L, Boden WE, Spacek R, et al. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA. 2005;293(23):2908–17.CrossRefGoogle Scholar
  7. 7.
    Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010;55(22):2435–45.CrossRefGoogle Scholar
  8. 8.
    Caruba T, Katsahian S, Schramm C, Charles Nelson A, Durieux P, Begue D, et al. Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies. PLoS One. 2014;9(6):e98371.CrossRefGoogle Scholar
  9. 9.
    Katritsis DG, Ioannidis JP. Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis. Circulation. 2005;111(22):2906–12.CrossRefGoogle Scholar
  10. 10.
    • Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. 2014;64(18):1929–49 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease.Google Scholar
  11. 11.
    Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, 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.CrossRefGoogle Scholar
  12. 12.
    Takaro T, Hultgren HN, Lipton MJ, Detre KM. The VA cooperative randomized study of surgery for coronary arterial occlusive disease II. Subgroup with significant left main lesions. Circulation. 1976;54(6 Suppl):Iii107–17.PubMedGoogle Scholar
  13. 13.
    VA Coronary Artery Bypass Surgery Cooperative Study Group. Eighteen-year follow-up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for stable angina. Circulation. 1992;86(1):121–30.CrossRefGoogle Scholar
  14. 14.
    Alderman EL, Bourassa MG, Cohen LS, Davis KB, Kaiser GG, Killip T, et al. Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation. 1990;82(5):1629–46.CrossRefGoogle Scholar
  15. 15.
    Varnauskas E. Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med. 1988;319(6):332–7.CrossRefGoogle Scholar
  16. 16.
    Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.CrossRefGoogle Scholar
  17. 17.
    Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121(24):2645–53.CrossRefGoogle Scholar
  18. 18.
    Mohr FW, Morice MC, Kappetein AP, Feldman TE, Stahle E, Colombo A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381(9867):629–38.CrossRefGoogle Scholar
  19. 19.
    BARI Investigators. The final 10-year follow-up results from the BARI randomized trial. J Am Coll Cardiol. 2007;49(15):1600–6.CrossRefGoogle Scholar
  20. 20.
    Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375–84.CrossRefGoogle Scholar
  21. 21.
    Brooks MM, Chaitman BR, Nesto RW, Hardison RM, Feit F, Gersh BJ, et al. Clinical and angiographic risk stratification and differential impact on treatment outcomes in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. Circulation. 2012;126(17):2115–24.CrossRefGoogle Scholar
  22. 22.
    Ikeno F, Brooks MM, Nakagawa K, Kim MK, Kaneda H, Mitsutake Y, et al. SYNTAX score and long-term outcomes: the BARI-2D trial. J Am Coll Cardiol. 2017;69(4):395–403.CrossRefGoogle Scholar
  23. 23.
    Mancini GB, Farkouh ME, Brooks MM, Chaitman BR, Boden WE, Vlachos H, et al. Medical treatment and revascularization options in patients with type 2 diabetes and coronary disease. J Am Coll Cardiol. 2016;68(10):985–95.CrossRefGoogle Scholar
  24. 24.
    • Stone GW, Hochman JS, Williams DO, Boden WE, Ferguson TB Jr, Harrington RA, et al. Medical therapy with versus without revascularization in stable patients with moderate and severe ischemia: the case for community equipoise. J Am Coll Cardiol. 2016;67(1):81–99 ISCHEMIA trial designed to address the benefit of routine revascularization in combination with medical therapy. Results expected in 2019.CrossRefGoogle Scholar
  25. 25.
    Gerber Y, Weston SA, Enriquez-Sarano M, Manemann SM, Chamberlain AM, Jiang R, et al. Atherosclerotic burden and heart failure after myocardial infarction. JAMA Cardiol. 2016;1(2):156–62.CrossRefGoogle Scholar
  26. 26.
    Hachamovitch R, Rozanski A, Shaw LJ, Stone GW, Thomson LE, Friedman JD, et al. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011;32(8):1012–24.CrossRefGoogle Scholar
  27. 27.
    Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS. Comparison of the short-term survival benefit associated with revascularization compared with medical therapy in patients with no prior coronary artery disease undergoing stress myocardial perfusion single photon emission computed tomography. Circulation. 2003;107(23):2900–7.CrossRefGoogle Scholar
  28. 28.
    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.CrossRefGoogle Scholar
  29. 29.
    •• 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. N Engl J Med. 2015;373(20):1937–46 The results of COURAGE trial comparing PCI with optimal medical therapy to optimal medical therapy alone.CrossRefGoogle Scholar
  30. 30.
    Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008;117(10):1283–91.CrossRefGoogle Scholar
  31. 31.
    Shaw LJ, Weintraub WS, Maron DJ, Hartigan PM, Hachamovitch R, Min JK, et al. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention. Am Heart J. 2012;164(2):243–50.CrossRefGoogle Scholar
  32. 32.
    Panza JA, Holly TA, Asch FM, She L, Pellikka PA, Velazquez EJ, et al. Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol. 2013;61(18):1860–70.CrossRefGoogle Scholar
  33. 33.
    •• Al-Lamee R, Thompson D, Dehbi HM, Sen S, Tang K, Davies J, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391(10115):31–40 The original ORBITA trial comparing PCI and intensive optimal therapy or intensive optimal therapy and a sham procedure.CrossRefGoogle Scholar
  34. 34.
    Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, 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
  35. 35.
    •• Bittner V, Bertolet M, Barraza Felix R, Farkouh ME, Goldberg S, Ramanathan KB, et al. Comprehensive Cardiovascular Risk Factor Control Improves Survival: The BARI 2D Trial. J Am Coll Cardiol. 2015;66(7):765–73 BARI 2D sub-analysis showing the importance of excellent risk factor control through protocol-guided intensive medical therapy.CrossRefGoogle Scholar
  36. 36.
    Stergiopoulos K, Boden WE, Hartigan P, Mobius-Winkler S, Hambrecht R, Hueb W, et al. Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: a collaborative meta-analysis of contemporary randomized clinical trials. JAMA Intern Med. 2014;174(2):232–40.CrossRefGoogle Scholar
  37. 37.
    De Bruyne B, Fearon WF, Pijls NH, Barbato E, Tonino P, Piroth Z, et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med. 2014;371(13):1208–17.CrossRefGoogle Scholar
  38. 38.
    Rioufol G, et al. FUTURE trial: treatment strategy in multivessel coronary disease patients based on fractional flow reserve. Presented at ESC 2018; August 25, 2018; Munich, Germany.Google Scholar
  39. 39.
    •• Al-Lamee R, Howard JP, Shun-Shin MJ, Thompson D, Dehbi HM, Sen S, 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(17):1780–92 Physiology-stratified analysis of ORBITA trial demonstrating benefit of PCI-revascularization on stress ECHO score and patient reported freedom from angina.CrossRefGoogle Scholar
  40. 40.
    • Norgaard BL, Terkelsen CJ, Mathiassen ON, Grove EL, Botker HE, Parner E, et al. Coronary CT angiographic and flow reserve-guided management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2018;72(18):2123–34 Use of CTA and FFRCT testing successfully differentiated patients who did not require further diagnostic testing or intervention (FFRCT > 0.80) from higher-risk patients (FFRCT ≤ 0.80) in whom further testing with invasive coronary angiography and possibly intervention may be required.Google Scholar
  41. 41.
    Gruntzig AR, Senning A, Siegenthaler WE. Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med. 1979;301(2):61–8.CrossRefGoogle Scholar
  42. 42.
    Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375(23):2223–35.CrossRefGoogle Scholar
  43. 43.
    Park S-J, Kim Y-H, Park D-W, Yun S-C, Ahn J-M, Song HG, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364(18):1718–27.CrossRefGoogle Scholar
  44. 44.
    Buszman PE, Buszman PP, Banasiewicz-Szkrobka I, Milewski KP, Zurakowski A, Orlik B, et al. Left Main stenting in comparison with surgical revascularization: 10-year outcomes of the (left main coronary artery stenting) LE MANS Trial. JACC Cardiovasc Interv. 2016;9(4):318–27.CrossRefGoogle Scholar
  45. 45.
    Park DW, Ahn JM, Yun SC, Yoon YH, Kang DY, Lee PH, et al. 10-year outcomes of stents versus coronary artery bypass grafting for left main coronary artery disease. J Am Coll Cardiol. 2018;72(23 Pt A):2813–22.CrossRefGoogle Scholar
  46. 46.
    •• Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH, et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet. 2018;391(10124):939–48 Metanalysis demonstrating similar all-cause mortality at 5 years between PCI and CABG revascularization of left main disease, regardless of diabetes status and SYNTAX score.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Konstantinos V. Voudris
    • 1
  • Clifford J. Kavinsky
    • 1
    Email author
  1. 1.Division of Cardiology, Department of MedicineRush University Medical CenterChicagoUSA

Personalised recommendations