Coronary artery disease (CAD) is a common condition which exists across a spectrum ranging from asymptomatic, subclinical disease to acute, life-threatening events. Between these extremes is a large population of patients with stable disease. The role of interventional procedures, primarily coronary artery angioplasty or stent placement, in treating acute coronary events such as myocardial infarction has been well-established, but for management of patients with stable CAD, the role of such intervention has been a subject of debate.
Angina pectoris is a common symptom, affecting up to 25% of patients with stable CAD. Previous studies have shown that lifestyle changes, pharmacologic treatment, and interventional procedures are all effective in improving symptoms, but the evidence has failed to show that interventional procedures provide an advantage in preventing acute events or death due to CAD.
In an article published last month in CIRCULATION, the authors present their analysis of data from CLARIFY, a longitudinal registry of patients with stable CAD.^[1]Mesnier J, Ducrocq G, Danchin N, et al.; CLARIFY Investigators. International Observational Analysis of Evolution and Outcomes of Chronic Stable Angina: The Multinational CLARIFY Study. Circulation. … Continue reading The registry enrolled almost 33,000 patients with stable CAD between 2009 and 2010. Participants have been followed over time, providing a window into the natural history of CAD and a better understanding of how various factors influence the course of the disease.
In this analysis, the authors looked at the incidence of acute coronary events over time to understand the factors associated with poor outcomes. They found that the primary predictor was the presence or absence of angina. In those whose angina was controlled, or in those who never experienced symptoms, the rate of cardiac events was low. In those whose angina persisted, the rate was high. Perhaps most notable was the finding that angina resolved with conservative management and without cardiac events in most patients. Based on their findings, the authors suggest that conservative management is an effective strategy for patients with stable angina. They also suggest that given the favorable evolution of angina and the low rate of events in most patients, a period of watchful waiting to determine the efficacy of medical management is reasonable.
This publication echoes the findings of the COURAGE, BARI 2D, ORBITA and ISCHEMIA trials, all of which support optimal medical therapy as the first line treatment of stable CAD, with interventional procedures reserved for those with persistent unacceptable ischemic symptoms.
Dr. Thomas Power, MD., FACC., is the medical director of Carelon Cardiology program and maintains an active cardiology practice. Per Dr. Power: “For several decades, interventional procedures have been widely used in the treatment of stable CAD, with the belief, held by both the patient and the treating physician, that the patient would fare better in the long term if the coronary stenosis was relieved. Accumulating, high-quality evidence indicates that for most stable CAD patients the only incremental benefit of PCI over optimal medical therapy (OMT) is in the relief of persistent unacceptable angina. Carelon expanded cardiology program ensures that OMT is instituted prior to intervention in stable CAD.”