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JOCELYN WRIGHT STENTING is ineffective for stable angina, according to a randomised trial, which cardiologists say is the“ last nail in the coffin” for the procedure.
Despite being in widespread use since the 1980s, a UK study shows percutaneous coronary intervention( PCI) is no better than a placebo procedure in patients with stable angina who are optimised on medical therapy.
The trial looked at active versus sham PCI interventions in 200 patients with stable angina and found no difference in outcomes, such as treadmill exercise time, at six weeks.
In an accompanying editorial in the Lancet, US cardiologists Professor David Brown and Professor Rita
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Redberg said the negative findings would have profound implications for a procedure that they dubbed“ routine, ingrained and profitable” when used in stable angina.
“ Based on these data, all cardiology guidelines should be revised to downgrade the recommendation for PCI in patients with angina despite the use of medical therapy,” they wrote.
They also questioned why it had taken 40 years for a widely used intervention to be subject to a blinded, randomised trial.
However, Professor Richard Harper, head of Monash Heart in Melbourne, cautioned that the authors went too far with their‘ nail in the coffin’ verdict.
He acknowledged that the trial was high quality and
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had put a question mark over the historical hypothesis that PCI offered angina relief over and above medical therapies, which had been based on trials without placebo controls.
But Professor Harper said PCI could still be a reasonable option in patients with refractory angina.
“ What we know so far is there is no evidence that, in stable coronary disease, PCIs improve outcomes in terms of mortality and preventing heart attacks,” he told Australian Doctor.
“[ These results ] will cause a lot of consternation among interventional cardiologists, [ but ] there may yet be a subset of patients with severe ischemia who could benefit from PCI. But the results are not yet available,” he said.
Professor Harper chairs
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the MBS Review Taskforce’ s cardiac services clinical committee, which recently looked at the appropriate use of PCI in stable angina.
In a consultation document circulated in October, the committee proposed that the MBS item for PCI be split into separate items, for acute coronary syndrome and stable angina, to better identify the use of the procedure.
Medicare figures showed that there were about 28,000 PCI procedures reimbursed in 2016 for all indications.
Figures from the Victorian Cardiac Outcomes Registry showed that, in 2016, 66 % of PCI procedures for nonacute coronory syndrome indications were for patients with stable angina. Lancet 2017; online.
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There were no differences in outcomes between active and sham stent procedures for patients with stable angina. |