Stable ischemic heart disease: Indications for revascularization
- Thomas Levin, MD
Thomas Levin, MD
- Illinois Heart and Vascular
- Chicago, Illinois
- Julian M Aroesty, MD
Julian M Aroesty, MD
- Clinical Associate Professor of Medicine
- Harvard Medical School
The goals of therapy in patients with stable ischemic heart disease, which includes individuals with severe symptoms to those who are asymptomatic, are to alleviate symptoms, delay or prevent the progression of coronary artery disease, and decrease the risk of adverse outcomes such as death, heart failure, or myocardial infarction. To this end, all patients should receive optimal medical therapy. Revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is reserved for:
●Patients with unacceptable angina
●Patients likely to have a survival benefit from revascularization, based upon the location and severity of the lesion, the number of diseased vessels, and the presence of left ventricular dysfunction.
The efficacy of medical therapy compared to revascularization in patients with stable ischemic heart disease will be reviewed here. The choice between PCI and CABG when revascularization is required is discussed separately. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)
The role of revascularization in patients with acute coronary syndromes (myocardial infarction and unstable angina) is discussed elsewhere. (See "Overview of the acute management of ST elevation myocardial infarction", section on 'Reperfusion' and "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction", section on 'Immediate angiography and revascularization'.)
- Alderman EL, Kip KE, Whitlow PL, et al. Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the Bypass Angioplasty Revascularization Investigation (BARI). J Am Coll Cardiol 2004; 44:766.
- 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; 344:563.
- Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med 1984; 311:1333.
- Myers WO, Schaff HV, Gersh BJ, et al. Improved survival of surgically treated patients with triple vessel coronary artery disease and severe angina pectoris. A report from the Coronary Artery Surgery Study (CASS) registry. J Thorac Cardiovasc Surg 1989; 97:487.
- Passamani E, Davis KB, Gillespie MJ, Killip T. A randomized trial of coronary artery bypass surgery. Survival of patients with a low ejection fraction. N Engl J Med 1985; 312:1665.
- Alderman EL, Bourassa MG, Cohen LS, et al. Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation 1990; 82:1629.
- Varnauskas E. Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med 1988; 319:332.
- Windecker S, Stortecky S, Stefanini GG, et al. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. BMJ 2014; 348:g3859.
- Kaiser GC, Davis KB, Fisher LD, et al. Survival following coronary artery bypass grafting in patients with severe angina pectoris (CASS). An observational study. J Thorac Cardiovasc Surg 1985; 89:513.
- Hueb W, Soares PR, Gersh BJ, et al. The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol 2004; 43:1743.
- Weiner DA, Ryan TJ, McCabe CH, et al. Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984; 3:772.
- Shaw LJ, Peterson ED, Shaw LK, et al. Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups. Circulation 1998; 98:1622.
- Katritsis DG, Ioannidis JP. Percutaneous coronary intervention versus conservative therapy in nonacute coronary artery disease: a meta-analysis. Circulation 2005; 111:2906.
- 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; 356:1503.
- Sedlis SP. Effect of PCI. N Engl J Med 2015; :1937.
- Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172:312.
- Bangalore S, Pursnani S, Kumar S, Bagos PG. Percutaneous coronary intervention versus optimal medical therapy for prevention of spontaneous myocardial infarction in subjects with stable ischemic heart disease. Circulation 2013; 127:769.
- Shaw LJ, Berman DS, Maron DJ, 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; 117:1283.
- 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; 367:991.
- Gada H, Kirtane AJ, Kereiakes DJ, et al. Meta-analysis of trials on mortality after percutaneous coronary intervention compared with medical therapy in patients with stable coronary heart disease and objective evidence of myocardial ischemia. Am J Cardiol 2015; 115:1194.
- Erne P, Schoenenberger AW, Burckhardt D, et al. Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: the SWISSI II randomized controlled trial. JAMA 2007; 297:1985.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: 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; 126:3097.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 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:e354.
- De Bruyne B, Fearon WF, Pijls NH, et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med 2014; 371:1208.
- Boden WE. Which is more enduring--FAME or COURAGE? N Engl J Med 2012; 367:1059.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
- Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:2574.
- Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
- OUR APPROACH
- OPTIMAL MEDICAL THERAPY
- INDICATIONS FOR NONINVASIVE TESTING
- INDICATIONS FOR CORONARY ANGIOGRAPHY
- INDICATIONS FOR CABG
- Improvement in survival
- Relief of angina
- INDICATIONS FOR PCI
- Improvement in survival
- Relief of angina
- PATIENTS WITHOUT CLEAR INDICATIONS
- Patient preference
- Severity of coronary artery disease
- Reduced left ventricular systolic function
- CABG VERSUS PCI
- Patients with diabetes
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS