Thursday, December 05, 2013


There is no doubt that Interventional Cardiology has gained wide acceptance and so all the detractors and opposers are out with their knives, schivers, folks and what have you. Doctors are being drag to court over charges of stent abuse, especially DES ( Drug Eluting Stents ).
In 2007, the COURAGE trial came out showing that PCI was doing no better than Optimal Medical Therapy accept for better symptom relief. So interventionist were told that we were doing PCI carelessly on all and sundry.  The interventionist replied by saying that a sub group of COURAGE ( the group with inducible ischemia ), should greater benefit with PCI. That was the guideline then. That we should intervene on symptoms and inducible ischemia.
Well, in the latest issue of JAMA - Internal Medicine, the workers from State University New York ( Sunny Brooks ), published a meta-analysis of 5,286 patients of which 4,064 had inducible ischemia.  The lead authors is Dr Kathleen Stergiopoulus. These were patients from the MASS II, COURAGE, BARI 2D, and FAME 2 trial. Their analysis revealed that ischemia seemed to make no difference.  Those with ischemia, on medical therapy, did as well after 5 years follow-up as those who had angioplasty, except that there was significantly less angina. Even FFR did not seem to make a difference.

Now we are all confused? Looks like, if Dr Kathleen and group is to be believed, PCI should only be done for acute coronary syndromes.

Looks like PCI is in a flax. The cosmetic effects are gone. People are not so seduced by smooth straight arterial walls for coronary arteries anymore, especially the insurers who are paying the bills. They will find more and more studies and guidelines to limit what we should and should not do.

As for me, I still would use inducible ischemia to separate those that should get intervention from those who should get optimal medical therapy. I do spend 30 mins counselling them.
I think that Dr Kathleen's conclusion may have to be tested in a properly conducted Randomised Controlled Trial. It is too important a conclusion to be left to meta-analysis data.

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