Effect of PCI on Quality of Life in Patients with Stable Coronary Disease

Abstract

Conclusions: In patients with stable angina, those treated with percutaneous coronary intervention (PCI) and optimal medical management, and those treated with optimal medical management both have marked improvement in quality of life during follow-up. Initially, those treated with PCI have a small incremental benefit vs those treated with medical management alone. After 36 months there is no difference in health status between the two groups. Summary: Up to one-third of PCIs have been performed in patients with stable angina. This is despite the fact that patients with chronic coronary disease do not have a reduction in major cardiovascular events when treated with PCI vs best medical management. The argument has been made that PCI reduces angina symptoms more effectively than best medical management and therefore improves quality of life. In this study the authors analyzed quality of life data to determine whether quality of life was enhanced by a strategy of PCI in patients with chronic coronary artery disease. This was a randomized, not blinded, multicenter trial that took place in 50 centers in the United States and Canada, with sponsorship and oversight of the trial provided by the Department of Veterans' Affairs Cooperative Studies Program. The study randomly assigned 2287 patients with stable coronary artery disease to optimum medical therapy alone, or PCI plus optimal medical therapy. Angina-specific health status was assessed using the Seattle Angina Questionnaire. Scores ranged from 0 to 100, with highest scores indicating better health status. The RAND 36-Item Health Survey was used to assess overall physical and mental function. Upon entering the trial, 22% of the patients were free of angina. After 3 months, 42% in the medical therapy group alone and 53% of the PCI patients were angina-free (P < .001). The mean ± SD Seattle Angina Questionnaire scores at baseline were 66 ± 25 for physical limitations, 54 ± 32 for angina stability, 69 ± 26 for angina frequency, 87 ± 16 for treatment satisfaction, and 51 for quality of life. By 3 months these baseline scores increased more in the PCI group compared with the medical therapy group: 76 ± 24 vs 72 ± 23 for physical limitation (P = .004), 77 ± 28 vs 73 ± 27 for anginal stability (P = .002), 85 ± 22 vs 80 ± 23 for angina frequency (P <.001), 92 ± 12 vs 90 ± 14 for treatment satisfaction (P < .001), and 73 ± 22 vs 68 ± 23 for quality of life (P < .001). Overall, incremental benefit for PCI was present for 6 to 24 months, and patients with more severe angina had greater benefit from PCI. Similar results occurred in the PCI group in some, but not all, RAND-36 domains. At 36 months there was no significant difference in health status between the two groups. Comment: This was not a “head to head” trial of medical therapy vs PCI. The trial, in fact, compared a strategy of initial PCI plus optimal medical therapy vs optical medical therapy alone initially. Eventually 21% of the patients in the medical therapy alone group crossed over and received PCI. Therefore, what this trial tells us is that in patients with stable coronary disease, initial management should be optimal medical therapy, and if this is ineffective, patients should then be treated with coronary intervention.