DÄ internationalArchive45/2009Different Treatment Options in Chronic Coronary Artery Disease—When Is It the Time for Medical Treatment, Percutaneous Coronary Intervention or Aortocoronary Bypass Surgery? Let's Go Down to Brass Tacks

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Different Treatment Options in Chronic Coronary Artery Disease—When Is It the Time for Medical Treatment, Percutaneous Coronary Intervention or Aortocoronary Bypass Surgery? Let's Go Down to Brass Tacks

Dtsch Arztebl Int 2009; 106(45): 749. DOI: 10.3238/arztebl.2009.0749a

Sroka, K

LNSLNS The authors comment on percutaneous coronary intervention (PCI) in a slightly intricate manner—namely, that medical treatment in chronic coronary heart disease (CHD) is not inferior to PCI with regard to the end point “lethality”. What is needed here is some plain speaking. All large studies, from RITA-2 (1997) to COURAGE (2007), which compared PCI with conservative treatment in chronic stable CHD have shown that balloon angioplasty with our without stenting does not prevent myocardial infarctions or prolong life, whether one or multiple vessels are affected. In this indication, PCI is clearly a merely palliative measure to alleviate the symptoms of angina pectoris without improving the prognosis. A publication from the Mayo Clinic (1) states very clearly:

• Percutaneous transluminal coronary angioplasty (PTCA) is indicated for the improvement of symptoms
• PTCA does not prevent death or myocardial infarction
• Stents decrease rates of angiographic restenosis repeat procedures but not those of death or myocardial infarction.
• With regard to aortocoronary bypass (ACB) surgery, the Mayo Clinic (1) says:
• ACB is effective in improving symptoms
• ACB does not reduce the incidence of nonfatal myocardial infarction
• The survival advantages of ACB are proportional to the patient’s original, pre-existing risk. It is recommended for different high-rist patients. This degree of clarity is lacking in the current article.

A courageous team of experts might have made the following recommendation in Deutsches Ärzteblatt: we propose that all general practitioners, cardiologists, and cardiovascular surgeons explain to their patients with chronic stable angina, before performing PCI or ACB, that these interventions do improve symptoms but do not prevent infarction nor prolong life, except in high risk patients. Therefore, treatment alternatives for the future would not be “stent or bypass,” but lifestyle modifications would become the decisive factor in improving the prognosis. Much more effective work could be done in this area without constantly waving the balloon catheter around.

If dilating or bypassing coronary stenoses in chronic ischemic heart disease have practically no influence on morbidity and mortality, the pathogenetic importance of high grade coronary stenoses is questionable. But this means touching on a taboo!
DOI: 10.3238/arztebl.2009.0749a

Dr. med. Knut Sroka
Stellinger Weg 47
20255 Hamburg, Germany
knut.sroka@hamburg.de
1.
Rihal CS, et al.: Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina. Review of Evidence and Methodological Considerations. Circulation 2003; 108: 2439–45.
2.
Ruß M, Cremer J, Krian A, Meinertz T, Werdan K, Zerkowski HR: Different treatment options in chronic coronary artery disease— when is it the time for medical treatment, percutaneous coronary intervention or aortocoronary bypass surgery? [Differenzialtherapie der chronischen koronaren Herzkrankheit – Wann medikamentöse Therapie, wann perkutane Koronarintervention, wann aortokoronare Bypassoperation?] Dtsch Arztebl Int 2009; 106(15): 253–61.
1. Rihal CS, et al.: Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina. Review of Evidence and Methodological Considerations. Circulation 2003; 108: 2439–45.
2. Ruß M, Cremer J, Krian A, Meinertz T, Werdan K, Zerkowski HR: Different treatment options in chronic coronary artery disease— when is it the time for medical treatment, percutaneous coronary intervention or aortocoronary bypass surgery? [Differenzialtherapie der chronischen koronaren Herzkrankheit – Wann medikamentöse Therapie, wann perkutane Koronarintervention, wann aortokoronare Bypassoperation?] Dtsch Arztebl Int 2009; 106(15): 253–61.