Abstract
The question of how to optimally manage coronary artery disease (CAD) has been a challenge for the cardiology community. The results of early, large randomized clinical trials (RCTs) comparing strategies of medical therapy alone versus revascularization plus medical therapy in patients with stable CAD suggested a survival advantage for a revascularization strategy in the setting of more advanced, higher-risk CAD (left main, three-vessel CAD), but a superiority of medical therapy in patients with more limited, relatively lower-risk CAD (one vessel, limited two-vessel CAD). The results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials redefined the management of CAD, supporting the concept that the impact of aggressively applied modern “medical therapy” on patient survival and patient-reported outcomes is not further improved by the addition of percutaneous intervention. On the other hand, RCTs incorporating fractional flow reserve have shown that this physiologic metric can help identify which patients will benefit from a revascularization strategy. This paradigm has been extended to the use of myocardial perfusion imaging-identified ischemia to determine which patients may have enhanced survival with early revascularization versus medical therapy. Although data from a series of observational studies suggest that inducible ischemia on myocardial perfusion scintigraphy can identify revascularization candidates, several studies, including substudies from major RCTs, do not support this idea. Until RCTs comparing revascularization with medical therapy strategies are performed, many questions remain open. The correct thresholds for treatment, the metric to guide treatment, and how revascularization should be performed are as yet undefined.
Zusammenfassung
Die Frage, wie die koronare Herzkrankheit (KHK) optimal zu behandeln ist, ist noch immer eine Herausforderung für die kardiologisch Tätigen. Die Ergebnisse früher, großer, randomisierter klinischer Studien (RCTs) zum Vergleich von Strategien medikamentöser Therapie versus Revaskularisierung plus medikamentöse Therapie bei Patienten mit stabiler KHK ergaben einerseits Hinweise auf einen Überlebensvorteil bei der Revaskularisierungsstrategie für die fortgeschrittenere KHK mit höherem Risiko (linker Hauptstamm, 3-Gefäß-KHK), aber andererseits Hinweise auf die Überlegenheit der medikamentösen Therapie bei Patienten mit eher schwach ausgeprägter KHK mit relativ niedrigem Risiko (Eingefäß-, schwach ausgeprägte 2-Gefäß-KHK). Die Ergebnisse der Studien Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) und Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) definierten die Therapie der KHK neu und unterstützten die Auffassung, dass der Einfluss aggressiv angewandter moderner „medikamentöser Therapie“ auf Patientenüberleben und von Patienten angegebene Ergebnisse nicht weiter durch eine zusätzliche perkutane Intervention verbessert wird. Andererseits hat sich in RCTs zur fraktionellen Flussreserve gezeigt, dass sich mit diesem physiologischen Parameter Patienten erkennen lassen, bei denen eine Revaskularisierungsstrategie von Vorteil ist. Dieses Paradigma wurde ausgeweitet auf den Einsatz der durch Myokardperfusionsbildgebung diagnostizierten Ischämie, um zu erkennen, welche Patienten möglicherweise ein höheres Überleben unter früher Revaskularisierung versus medikamentöser Therapie aufweisen. Obwohl sich aus den Daten einer Reihe von Beobachtungsstudien Hinweise ergeben, dass eine induzierbare Ischämie in der Myokardperfusionsszintigraphie (MPS) zur Erkennung von Revaskularisierungskandidaten führen kann, ist dies in verschiedenen Studien einschließlich Substudien großer RCTs nicht der Fall. Bis RCTs zum Vergleich von Revaskularisierungs- mit medikamentösen Therapiestragien durchgeführt werden, bleiben viele Fragen. Welches die richtigen Grenzwerte für die Behandlung sind, welcher Parameter therapieführend sein sollte und wie die Revaskularisierung erfolgen sollte, ist bis jetzt nicht festgelegt.
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Hachamovitch, R. Impact of ischemia and scar on therapeutic benefit of myocardial revascularization. Herz 38, 344–349 (2013). https://doi.org/10.1007/s00059-013-3804-4
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DOI: https://doi.org/10.1007/s00059-013-3804-4