Evolving concepts in selecting optimal strategies for the management of patients with stable coronary disease: pharmacologic or revascularization therapy

Abstract

Initial management of patients with stable ischemic heart disease (SIHD) continues to be vigorously debated amongst cardiologists. Despite the lack of robust data to support percutaneous coronary intervention (PCI) as the initial management of SIHD patients, it remains one of the most commonly performed procedures. Results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial reignited the controversy of the benefit of routine initial PCI over optimal medical therapy (OMT). The trial suggested that, as an initial management strategy in patients with SIHD, PCI did not reduce the risk of death, myocardial infarction, or any other major cardiovascular events, when added to OMT. A meta-analysis from Schomig et al. suggests that a PCI-based invasive strategy may improve long-term survival compared with solely medical treatment in stable coronary artery disease patients. As the ability to mechanically dilate obstructive coronary arterial stenoses has vastly improved our approach to managing patients with SIHD, the result has been a swing from an initial pharmacologic approach. An improved understanding of the pathophysiology of acute coronary syndrome, increased insight into plaque and patient vulnerability has led to the more aggressive use of appropriately targeted pharmacologic agents and an evolution in what constitutes OMT, based largely on the results of the COURAGE trial. Recent studies support the concept that, in SIHD patients, OMT alone compares favorably with a therapeutic strategy combining OMT with mechanical intervention. Thus, the treatment pendulum may be swinging back to the understanding that 'best practice' today requires the judicious use of interventional and medical therapies in the appropriate patient population.