Chronic stable angina pectoris: Revascularization

Revascularization

Revascularization includes either percutaneous coronary intervention (i.e., balloon angioplasty and stenting) or coronary-artery bypass surgery. More than 1 million percutaneous coronary interventions were performed in the United States in 2003, far surpassing the number of surgical revascularizations. More than 80 percent of percutaneous interventions in the United States in 2004 were performed with the use of drug-eluting stents coated with sirolimus or paclitaxel.

Revascularization (performed by any technique) has not been shown to decrease the risk of myocardial infarction or death from coronary artery disease in patients with chronic stable angina and preserved left ventricular function.

However, revascularization should be considered for persons with lifestyle-limiting angina who have a good medical regimen or for those with high-risk factors, such as symptomatic multivessel disease, proximal left anterior descending or left main artery disease, left ventricular systolic dysfunction, Diabetes, a large ischemic burden on nuclear or echocardiographic stress testing, early onset of ischemia on stress testing, or ST-segment depression of 2 mm or more. Although coronary-artery bypass surgery achieves more complete and durable control of angina than percutaneous coronary intervention (with the use of noncoated stents), subsequent rates of myocardial infarction and death are similar over a five-year period with the two strategies. Trials in which the use of noncoated stents were compared with balloon angioplasty have not shown significant differences in the rate of major adverse events, including acute myocardial infarction and death. The long-term effect of drug-eluting stents on outcomes in chronic stable angina is still under evaluation; current data indicate that there have been significant reductions in the rate of restenosis at 6 to 12 months with coated stents, as compared with noncoated stents, resulting in substantial decreases in recurrent angina and the need for revascularization of target lesions. It is not clear how the long-term outcomes compare with those of coronary-artery bypass grafting. Decisions regarding strategies for revascularization should take into account patients' preferences and local experience.

Cardioprotective Therapy versus Percutaneous Intervention

Marked regional variability in the use of revascularization procedures suggests excessive use in some geographic areas. Several trials have indicated that treatment with a combination of vasculoprotective agents, along with lifestyle changes - with the option to proceed to percutaneous revascularization if symptoms worsen - results in rates of myocardial infarction and death that are not significantly different from those associated with revascularization in patients with class I or II stable angina whose disease involves one or two vessels.