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| | __NOTOC__ |
| {{Chronic stable angina}} | | {{Chronic stable angina}} |
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| '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]; [[Lakshmi Gopalakrishnan, M.B.B.S.]] | | '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]; [[Lakshmi Gopalakrishnan, M.B.B.S.]]; {{AA}} Jair Basantes de la Calle, M.D. |
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| ==Overview== | | ==Overview== |
| Percutaneous coronary intervention for [[coronary artery disease]] first began in 1977, as a valuable mode of revascularization, wherein at the point of [[stenosis|coronary stenosis]] a catheter-borne balloon is inflated to relieve the stenosis. The '''advantages''' of PCI for the treatment of [[CAD]] are many and include a low level of procedure-related morbidity and mortality rate in properly selected patients, a shorter hospital stay, early return to activity, and the feasibility of multiple procedures. The risk of acute coronary occlusion during PCI and increased incidence of [[restenosis]] in lesions that were successfully treated '''limits the use of PCI'''.<ref name="pmid9468204">Bauters C, Banos JL, Van Belle E, Mc Fadden EP, Lablanche JM, Bertrand ME (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9468204 Six-month angiographic outcome after successful repeat percutaneous intervention for in-stent restenosis.] ''Circulation'' 97 (4):318-21. PMID: [http://pubmed.gov/9468204 9468204]</ref><ref name="pmid10545431">Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10545431 Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome.] ''Circulation'' 100 (18):1872-8. PMID: [http://pubmed.gov/10545431 10545431]</ref> | | Percutaneous coronary intervention for [[coronary artery disease]] first began in 1977, as a valuable mode of revascularization, wherein at the point of [[stenosis|coronary stenosis]] a catheter-borne balloon is inflated to relieve the stenosis. |
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| '''Ideal candidates''' for PTCA/PCI include patients with stable angina less than 75 years of age, with single-vessel and/or single-lesion [[CAD]], without a history of [[diabetes]]. Objective large [[ischemia]], in particular, lesions less than 10 mm, readily accessible, concentric, and discrete are best suited for revascularization by PCI. On the contrary, chronic total occlusions that cannot be crossed, lesions greater than 20 mm, tortuous, irregular, angulated, calcified, severely stenotic with one or more lesion greater than 90% stenosis present in an artery are associated with an increased risk of morbidity and mortality from the procedure. In addition, PCI is used with reservation in [[diabetics]] with multi-vessel disease and in patients with unprotected [[left main]] stenosis. Other important factors include the operator volume and the presence or absence of onsite cardiovascular surgeon.<ref name="pmid16391169">Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16391169 ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention).] ''Circulation'' 113 (1):156-75. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.170815 DOI:10.1161/CIRCULATIONAHA.105.170815] PMID: [http://pubmed.gov/16391169 16391169]</ref>
| | ==PCI== |
| | ===Advantages=== |
| | The advantages of PCI for the treatment of [[CAD]] are many and include: |
| | * Low level of procedure-related morbidity and mortality rate in properly selected patients |
| | * Shorter hospital stay |
| | * Early return to activity |
| | * Overall feasibility of multiple procedures |
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| '''Primary success''' of coronary intervention is generally defined as an absolute increase of 20% points in the luminal diameter and a final diameter obstruction of less than 30%. Such angiographic success can be anticipated in more than 90% of properly selected patients.
| | ===Disadvantages=== |
| | The main disadvantages of PCI are: |
| | * Risk of acute coronary occlusion during PCI |
| | * Increased incidence of [[restenosis]] in lesions that were successfully treated. |
| | During clinical evaluation for treatment, these disadvantages must be considered and may limit the usage of this procedure.<ref name="pmid9468204">Bauters C, Banos JL, Van Belle E, Mc Fadden EP, Lablanche JM, Bertrand ME (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9468204 Six-month angiographic outcome after successful repeat percutaneous intervention for in-stent restenosis.] ''Circulation'' 97 (4):318-21. PMID: [http://pubmed.gov/9468204 9468204]</ref><ref name="pmid10545431">Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10545431 Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome.] ''Circulation'' 100 (18):1872-8. PMID: [http://pubmed.gov/10545431 10545431]</ref> |
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| Over the years, alternative methods of percutaneous treatment developed include the use of '''intracoronary brachytherapy''' for in-stent [[restenosis]],<ref name="pmid10653825">Teirstein PS, Massullo V, Jani S, Popma JJ, Russo RJ, Schatz RA et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10653825 Three-year clinical and angiographic follow-up after intracoronary radiation : results of a randomized clinical trial.] ''Circulation'' 101 (4):360-5. PMID: [http://pubmed.gov/10653825 10653825]</ref><ref name="pmid1205798">Salomon R, Soreq H, Givon D, Sela I, Littauer UZ (1975) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1205798 Proceedings: Enzymatic acylation of histidine to tobacco mosaic virus RNA.] ''Isr J Med Sci'' 11 (11):1208-9. PMID: [http://pubmed.gov/1205798 1205798]</ref> '''cutting balloon with metal razors''' to avoid the spillage and subsequent reduction in the incidence of vessel trauma, '''burr rotablation''' that pulverizes the atheromatous material<ref name="pmid11170330">Kobayashi Y, Teirstein P, Linnemeier T, Stone G, Leon M, Moses J (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11170330 Rotational atherectomy (stentablation) in a lesion with stent underexpansion due to heavily calcified plaque.] ''Catheter Cardiovasc Interv'' 52 (2):208-11. PMID: [http://pubmed.gov/11170330 11170330]</ref> and '''intracoronary stents''' designed to maintain the lumen size.
| | ===Indications=== |
| | Ideal candidates for PTCA/PCI include patients: |
| | * Less than 75 years of age with stable angina |
| | * With single-vessel and/or single-lesion [[CAD]] |
| | * Without a history of [[diabetes]] |
| | * With objective large [[ischemia]] - in particular, lesions less than 10 mm, readily accessible, concentric, and discrete are best suited for revascularization by PCI |
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| ==Indications== | | ===Contraindications=== |
| *'''PCI has been shown to reduce the frequency of anginal symptoms and improve exercise tolerance in patients with single and double-vessel [[coronary artery disease]].'''
| | On the contrary, chronic total occlusions that cannot be crossed, lesions greater than 20 mm, tortuous, irregular, angulated, calcified, severely stenotic with one or more lesion greater than 90% stenosis present in an artery are associated with an increased risk of morbidity and mortality from the procedure. In addition, PCI is used with reservation in [[diabetics]] with multi-vessel disease and in patients with unprotected [[left main]] stenosis. Other important factors include the operator volume and the presence or absence of onsite cardiovascular surgeon.<ref name="pmid16391169">Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16391169 ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention).] ''Circulation'' 113 (1):156-75. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.170815 DOI:10.1161/CIRCULATIONAHA.105.170815] PMID: [http://pubmed.gov/16391169 16391169]</ref> |
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| :*In the '''ACME trial''', approximately 213 patients with stable single-vessel [[CAD]] were assessed to compare the effects of PCI with [[Chronic stable angina pharmacotherapy overview|medical therapy]] on angina and exercise tolerance. The study demonstrated that PCI offered earlier and more complete relief of angina than [[Chronic stable angina pharmacotherapy overview|medical therapy]] ''(64% patients in PCI group versus 46% medically treated group; p=less than 0.01)'' and was associated with a better exercise tolerance ''(2.1 in the PCI group versus 0.5 minutes in the medically treated group; p=less than 0.0001)'' as observed at 6-month follow-up.<ref name="pmid1345754">Parisi AF, Folland ED, Hartigan P (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1345754 A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.] ''N Engl J Med'' 326 (1):10-6. [http://dx.doi.org/10.1056/NEJM199201023260102 DOI:10.1056/NEJM199201023260102] PMID: [http://pubmed.gov/1345754 1345754]</ref>
| | ===Primary Success=== |
| | Primary success of coronary intervention is generally defined as an absolute increase of 20% points in the luminal diameter and a final diameter obstruction of less than 30%. Such angiographic success can be anticipated in more than 90% of properly selected patients. |
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| :*In a '''sub-study''' that assessed the long-term effectiveness of PCI for single-vessel [[CAD]], demonstrated sustained benefits with PCI similar to the ACME trial, hence making it an attractive therapeutic option.<ref name="pmid9874045">Hartigan PM, Giacomini JC, Folland ED, Parisi AF (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9874045 Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine.] ''Am J Cardiol'' 82 (12):1445-50. PMID: [http://pubmed.gov/9874045 9874045]</ref> | | Over the years, alternative methods of percutaneous treatment developed include the use of: |
| | * Intracoronary brachytherapy for in-stent [[restenosis]].<ref name="pmid10653825">Teirstein PS, Massullo V, Jani S, Popma JJ, Russo RJ, Schatz RA et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10653825 Three-year clinical and angiographic follow-up after intracoronary radiation : results of a randomized clinical trial.] ''Circulation'' 101 (4):360-5. PMID: [http://pubmed.gov/10653825 10653825]</ref><ref name="pmid1205798">Salomon R, Soreq H, Givon D, Sela I, Littauer UZ (1975) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1205798 Proceedings: Enzymatic acylation of histidine to tobacco mosaic virus RNA.] ''Isr J Med Sci'' 11 (11):1208-9. PMID: [http://pubmed.gov/1205798 1205798]</ref> |
| | * Cutting balloon with metal razors to avoid the spillage and subsequent reduction in the incidence of vessel trauma. |
| | * Burr rotablation that pulverizes the atheromatous material.<ref name="pmid11170330">Kobayashi Y, Teirstein P, Linnemeier T, Stone G, Leon M, Moses J (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11170330 Rotational atherectomy (stentablation) in a lesion with stent underexpansion due to heavily calcified plaque.] ''Catheter Cardiovasc Interv'' 52 (2):208-11. PMID: [http://pubmed.gov/11170330 11170330]</ref> |
| | * Intracoronary stents designed to maintain the lumen size. |
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| *'''In patients with [[Ischemia|objective large ischemia]] associated with severe angina, PCI has shown to significantly reduce mortality and provide greater symptomatic improvement. However, on the contrary, patients with mild symptoms do not benefit from PCI.''' | | ==PCI in Patients with Chronic Stable Angina== |
| | *'''[[Chronic stable angina revascularization percutaneous coronary intervention indications|Indications]]''' |
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| :*In the '''ACIP study''', that compared the 12-week efficacy of the three treatment strategies such as [[Chronic stable angina pharmacotherapy overview|medical therapy]], [[Chronic stable angina pharmacotherapy overview|medical therapy]] plus [[Chronic stable angina ambulatory ST segment monitoring|ambulatory ECG monitoring]] or [[Chronic stable angina revascularization|revascularization]] to suppress [[ischemia|cardiac ischemia]], and to assess the feasibility of a [[Chronic stable angina prognosis|prognosis]] trial in patients with asymptomatic cardiac ischemia, demonstrated both stress-inducible ischemia and two or more ischemic episodes on holter monitoring.<ref name="pmid8006249">Pepine CJ, Geller NL, Knatterud GL, Bourassa MG, Chaitman BR, Davies RF et al. (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8006249 The Asymptomatic Cardiac Ischemia Pilot (ACIP) study: design of a randomized clinical trial, baseline data and implications for a long-term outcome trial.] ''J Am Coll Cardiol'' 24 (1):1-10. PMID: [http://pubmed.gov/8006249 8006249]</ref> Two years after randomization, the total mortality was significantly reduced from 6.6% in the angina-guided strategy to 4.4% in the ischemia-guided strategy and 1.1% in the revascularization strategy ''(p=less than 0.02)''. The rate of composite primary end-points was also significantly reduced from 41.8% in the angina-guided strategy to 38.5% in the ischemia-guided strategy and 23.1% in the revascularization strategy ''(p=less than 0.001)''.<ref name="pmid9133513">Davies RF, Goldberg AD, Forman S, Pepine CJ, Knatterud GL, Geller N et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9133513 Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization.] ''Circulation'' 95 (8):2037-43. PMID: [http://pubmed.gov/9133513 9133513]</ref>
| | *'''[[Coronary artery disease treatment in diabetics#Percutaneous Revascularization|PCI in diabetics]]''' |
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| :*The '''RITA-2 trial''' compared the long-term effects of PCI and [[Chronic stable angina pharmacotherapy overview|conventional medical therapy]] in patients with [[CAD]], demonstrated an early intervention with PCI was associated with greater symptomatic improvement, particularly observed in patients with more severe angina. However, on the contrary, the primary composite end-points during a median 2.7 year follow-up was significantly higher in patients treated with PCI than in patients treated with medical therapy ''(6.3% in the PCI group versus 3.3% in the medically treated group; p=0.02)''.<ref name="pmid9274581"> (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9274581 Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. RITA-2 trial participants.] ''Lancet'' 350 (9076):461-8. PMID: [http://pubmed.gov/9274581 9274581]</ref>
| | *'''[[Chronic stable angina revascularization drug eluting stents|Drug eluting stents in PCI]]''' |
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| :*A '''meta-analysis''' of six randomized controlled trials that assessed the benefit of PCI versus [[Chronic stable angina pharmacotherapy overview|medical treatment]] for patients with [[CAD|non-acute coronary heart disease]], reported that PCI may lead to a greater reduction in angina in patients with CAD in comparison to [[Chronic stable angina pharmacotherapy overview|medical therapy]]; however, sufficient patients were not included to assess the effect of PCI on [[MI]], death, or subsequent [[Chronic stable angina revascularization|revascularization]].<ref name="pmid10884254">Bucher HC, Hengstler P, Schindler C, Guyatt GH (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10884254 Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials.] ''BMJ'' 321 (7253):73-7. PMID: [http://pubmed.gov/10884254 10884254]</ref>
| | *'''[[Chronic stable angina revascularization adjunctive pharmacotherapy for percutaneous coronary intervention|Adjunctive pharmacotherapy]]''' |
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| :*The '''AVERT trial''', demonstrated that in patients with [[Chronic stable angina assessing the pretest probability of coronary artery disease|low-risk]] for [[coronary artery disease]], an initial [[Chronic stable angina treatment anti-lipid agents|aggressive lipid-lowering therapy]] aimed at reversing plaque growth and promoting plaque stabilization, had significantly prolonged the time to first ischemic event ''(p=0.03)'' when compared to [[Chronic stable angina revascularization|PCI]] and [[Chronic stable angina pharmacotherapy overview|standard medical therapy]]. Hence, in low-risk patients with stable [[CAD]], it is beneficial to start with medical therapy and reserve revascularization strategies for non-responders.<ref name="pmid10395630">Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10395630 Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators.] ''N Engl J Med'' 341 (2):70-6. [http://dx.doi.org/10.1056/NEJM199907083410202 DOI:10.1056/NEJM199907083410202] PMID: [http://pubmed.gov/10395630 10395630]</ref><ref name="pmid11174355">Amoroso G, Van Boven AJ, Crijns HJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11174355 Drug therapy or coronary angioplasty for the treatment of coronary artery disease: new insights.] ''Am Heart J'' 141 (2 Suppl):S22-5. PMID: [http://pubmed.gov/11174355 11174355]</ref>
| | *'''[[Chronic stable angina revascularization complications of percutaneous coronary intervention|Complications of PCI]]''' |
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| :*In the '''TIME study''', that assessed the long-term survival and quality of life in elderly patients with [[Canadian cardiovascular society classification of angina pectoris|CCS]] class II or greater angina receiving atleast two anti-anginal medication at baseline, demonstrated similar long-term survival benefits observed in both the groups; however, freedom from major cardiovascular events remained higher in invasive therapy group versus the medical therapy group ''(39% versus 20%, p=less than 0.0001)''. Irrespective of whether patients were catheterized initially or only after failure to respond to [[Chronic stable angina pharmacotherapy overview|medical therapy]], their survival rates were better if they were revascularized within the first year.<ref name="pmid15337691">Pfisterer M, Trial of Invasive versus Medical therapy in Elderly patients Investigators (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15337691 Long-term outcome in elderly patients with chronic angina managed invasively versus by optimized medical therapy: four-year follow-up of the randomized Trial of Invasive versus Medical therapy in Elderly patients (TIME).] ''Circulation'' 110 (10):1213-8. [http://dx.doi.org/10.1161/01.CIR.0000140983.69571.BA DOI:10.1161/01.CIR.0000140983.69571.BA] PMID: [http://pubmed.gov/15337691 15337691]</ref>
| | *'''[[Chronic stable angina revascularization guidelines for percutaneous coronary intervention|Guidelines for PCI]]''' |
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| *'''Despite the high rates of [[restenosis]] associated with PCI, it may be beneficial for [[Occlusive coronary artery thrombus|chronic total occlusions]] only in cases where the distal lumen could be accessed and favorable results could be obtained with [[Stent|stent implantation]].'''
| | == 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Revascularization in Stable ischemic heart disease (Please do not edit). == |
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| :*The '''GISSOC trial''', studied the benefit of stent implantation over balloon PTCA for the treatment of chronic total coronary occlusions. The study demonstrated a significant reduction in the major adverse cardiovascular events observed in the stent group during a 6-year follow-up ''(76.1% in the stent group versus 60.4% in the PTCA group; p=0.055)'' and attributed this reduction secondary to the target lesion revascularization free-survival rate ''(85.1% in the stent group versus 65.5% in the PTCA group; p=0.0165)''. However, in most cases, [[restenosis]] of the study occlusion was evident at nine-month angiography. Thus, the study concluded stent implantation was superior to balloon PTCA in chronic total occlusions that can be recanalized percutaneously and is a valuable long-term therapeutic option; however, at nine-month follow-up both the stent and PTCA results appear to remain stable.<ref name="pmid12742287">Rubartelli P, Verna E, Niccoli L, Giachero C, Zimarino M, Bernardi G et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12742287 Coronary stent implantation is superior to balloon angioplasty for chronic coronary occlusions: six-year clinical follow-up of the GISSOC trial.] ''J Am Coll Cardiol'' 41 (9):1488-92. PMID: [http://pubmed.gov/12742287 12742287]</ref>
| | === Revascularization in Stable ischemic heart disease === |
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| :*Similar benefits with stent implantation for chronic total occlusion were reported in few other studies such as: | | === Left ventricular dysfunction and multivessel CAD === |
| ::*The '''PRISON study''', that demonstrated a statistically significant reduction in the need for target lesion revascularization ''(29% in the PTCA group versus 13% in the stent group; p=less than 0.0001)'' and a non-significant rate of [[restenosis]] was observed ''(33% in the PTCA group versus 22% in the stent group; p=0.137)''.<ref name="pmid15131557">Rahel BM, Suttorp MJ, Laarman GJ, Kiemeneij F, Bal ET, Rensing BJ et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15131557 Primary stenting of occluded native coronary arteries: final results of the Primary Stenting of Occluded Native Coronary Arteries (PRISON) study.] ''Am Heart J'' 147 (5):e22. [http://dx.doi.org/10.1016/j.ahj.2003.11.023 DOI:10.1016/j.ahj.2003.11.023] PMID: [http://pubmed.gov/15131557 15131557]</ref> | | {| class="wikitable" style="width:80%" |
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| | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
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| | | bgcolor="LightGreen" |"1'''.''' In patients with SIHD and multivessel CAD appropriate for CABG with severe left ventricular systolic dysfunction (left ventricular ejection fraction <35%), CABG is recommended to improve survival. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki> |
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| | | bgcolor="LemonChiffon" |<nowiki>''</nowiki>2. In selected patients with SIHD and multivessel CAD appropriate for CABG and mild to moderate left ventricular systolic dysfunction (ejection fraction 35%–50%), CABG (to include a left internal mammary artery [LIMA] graft to the LAD) is reasonable to improve survival (Level of evidence B-NR)<nowiki>''</nowiki> |
| | |} |
| | <ref name="pmid35286170">{{cite journal| author=| title=Correction to: 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 11 | pages= e771 | pmid=35286170 | doi=10.1161/CIR.0000000000001061 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35286170 }}</ref> |
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| ::*The '''STOP study''', demonstrated significant reduction in the rate of [[restenosis]] ''(42.1% in the stent group versus 70.9% in the PTCA group; p=0.034)'' and [[reocclusion]] ''(7.9% in the stent group versus 16.1% in the PTCA group)'' observed with the stent implantation. However, stent group was associated with more a diffuse in-stent restenosis in comparison to a focal re-stenosis in the PTCA group that occurred at the point of total obstruction (within 5mm).<ref name="pmid11071802">Lotan C, Rozenman Y, Hendler A, Turgeman Y, Ayzenberg O, Beyar R et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11071802 Stents in total occlusion for restenosis prevention. The multicentre randomized STOP study. The Israeli Working Group for Interventional Cardiology.] ''Eur Heart J'' 21 (23):1960-6. [http://dx.doi.org/10.1053/euhj.2000.2295 DOI:10.1053/euhj.2000.2295] PMID: [http://pubmed.gov/11071802 11071802]</ref> | | === Left main CAD === |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
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| | | bgcolor="LightGreen" |"3'''.''' In patients with SIHD and significant left main stenosis, CABG is recommended to improve survival''[[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki> |
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| | | bgcolor="LemonChiffon" |<nowiki>''</nowiki>4. In selected patients with SIHD and significant left main stenosis for whom PCI can provide equivalent revascularization to that possible with CABG, PCI is reasonable to improve survival. (Level of evidence B-NR)<nowiki>''</nowiki> |
| | |} |
| | <ref name="pmid35286170" /> |
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| ::*The '''SARECCO trial''', demonstrated a significant event free survival in the stent group observed during a 2-year follow-up ''(26% in the group that received angioplasty alone versus 52% in the stent group; p=less than 0.05)''.<ref name="pmid10468073">Sievert H, Rohde S, Utech A, Schulze R, Scherer D, Merle H et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10468073 Stent or angioplasty after recanalization of chronic coronary occlusions? (The SARECCO Trial).] ''Am J Cardiol'' 84 (4):386-90. PMID: [http://pubmed.gov/10468073 10468073]</ref> | | === Multivessel CAD === |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] |
| | |- |
| | | bgcolor="LemonChiffon" |" 5'''.''' In patients with SIHD, normal ejection fraction, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for CABG, CABG may be reasonable to improve survival (Level of Evidence B-R)". |
| | |- |
| | | bgcolor="LemonChiffon" |<nowiki>''</nowiki> 6. In patients with SIHD, normal ejection fraction, significant stenosis in 3 major coronary arteries (with or without proximal LAD), and anatomy suitable for PCI, the usefulness of PCI to improve survival is uncertain (Level of Evidence B-NR)<nowiki>''</nowiki> |
| | |} |
| | <ref name="pmid35286170" /> |
|
| |
|
| ::*The '''SPACTO trial''', demonstrated significant reduction in the rates of [[restenosis]] ''(29% in the stent group versus 72% in the PTCA group; p=less than 0.01)'' and [[reocclusion]] ''(3% in the stent group versus 24% in the PTCA group)'' observed in the stent group. At follow-up,there was also a significant reduction in cardiac events ''(p=less than 0.03)'' and marked improvement in the anginal class ''(p=less than 0.01)'' reported in the stent group.<ref name="pmid10483953">Höher M, Wöhrle J, Grebe OC, Kochs M, Osterhues HH, Hombach V et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10483953 A randomized trial of elective stenting after balloon recanalization of chronic total occlusions.] ''J Am Coll Cardiol'' 34 (3):722-9. PMID: [http://pubmed.gov/10483953 10483953]</ref>
| | === Stenosis in the proximal LAD artery === |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] |
| | |- |
| | | bgcolor="LemonChiffon" |" 7'''.''' In patients with SIHD, normal left ventricular ejection fraction, and significant stenosis in the proximal LAD, the usefulness of coronary revascularization to improve survival is uncertain (Level of Evidence B-R)". |
| | |} |
| | <ref name="pmid35286170" /> |
|
| |
|
| ::*The '''TOSCA study''', demonstrated stent implantation significantly improved late patency and reduced the rates of [[restenosis]] ''(70% in the PTCA group versus 55% in the stent group; p=less than 0.01)'' and target-vessel revascularization ''(15.4% in the PTCA group versus 8.4% in the stent group; p=0.03)''. Hence, the study concluded stent implantation being superior to PTCA for non-acute coronary occlusions.<ref name="pmid10411846">Buller CE, Dzavik V, Carere RG, Mancini GB, Barbeau G, Lazzam C et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10411846 Primary stenting versus balloon angioplasty in occluded coronary arteries: the Total Occlusion Study of Canada (TOSCA).] ''Circulation'' 100 (3):236-42. PMID: [http://pubmed.gov/10411846 10411846]</ref> | | === Single- or double-vessel disease not involving the proximal LAD === |
|
| | {| class="wikitable" style="width:80%" |
| ::*The '''SICCO trial''', reported a significant reduction in the target lesion revascularization ''(22% in the stent group versus 42% in the PTCA group; p=0.025)'' and [[restenosis]] ''(32% patients with stent and 74% patients with PTCA only; p=0.025)'' noted in the stent implantation group.<ref name="pmid8917256">Sirnes PA, Golf S, Myreng Y, Mølstad P, Emanuelsson H, Albertsson P et al. (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8917256 Stenting in Chronic Coronary Occlusion (SICCO): a randomized, controlled trial of adding stent implantation after successful angioplasty.] ''J Am Coll Cardiol'' 28 (6):1444-51. PMID: [http://pubmed.gov/8917256 8917256]</ref>
| | |- |
| | | colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) |
| | |- |
| | | bgcolor="LightCoral" |"8'''.''' In patients with SIHD, normal left ventricular ejection fraction, and 1 or 2 vessel CAD not involving the proximal LAD, coronary revascularization is not recommended to improve survival ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki> |
| | |} |
| | <ref name="pmid35286170" /> |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) |
| | |- |
| | | bgcolor="LightCoral" |"9'''. I'''n patients with SIHD who have ≥1 coronary arteries that are not anatomically or function-ally significant (<70% diameter of non–left main coronary artery stenosis, FFR >0.80), coronary revascularization should not be performed with the primary or sole intent to improve survival'''.''' ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR]])'' <nowiki>"</nowiki> |
| | |}<ref name="pmid35286170" /> |
|
| |
|
| :*In the '''PACTO study''', 48 consecutive patients received '''[[paclitaxel|paclitaxel-eluting stent]]''' implantation after successful recanalization of a chronic total occlusion, to assess the efficacy of drug-eluting stent in comparison to bare metal stent for the treatment of chronic total coronary occlusions. At 1-year follow-up, the incidence of major adverse cardiovascular events was significantly reduced in the [[paclitaxel]] group ''(12.5% in the Taxus group and 47.9% in the BMS group; p=less than 0.001)'' which was secondary to reduced need for repeat revascularization. The secondary end-points included the rate of [[restenosis]] ''(8.3% in the Taxus group and 51.1% in the BMS group; p=less than 0.001)'' and [[reocclusion]] ''(2.1% in the Taxus group and 23.4% in the BMS group; p=less than 0.005)'' which was also significantly reduced in the paclitaxel group. Thus, the study concluded, paclitaxel-eluting stent drastically reduced the incidence of major cardiovascular events and [[restenosis]], and almost eliminated [[reocclusion]] which is frequently observed with bare metal stents when used for chronic total occlusion.<ref name="pmid15607390">Werner GS, Krack A, Schwarz G, Prochnau D, Betge S, Figulla HR (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15607390 Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents.] ''J Am Coll Cardiol'' 44 (12):2301-6. [http://dx.doi.org/10.1016/j.jacc.2004.09.040 DOI:10.1016/j.jacc.2004.09.040] PMID: [http://pubmed.gov/15607390 15607390]</ref> | | === Revascularization to Reduce Cardiovascular Events in SIHD Compared With Medical Therapy === |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] |
| | |- |
| | | bgcolor="LemonChiffon" |" 1'''.''' In patients with SIHD and multivessel CAD appropriate for either CABG or PCI, revas-cularization is reasonable to lower the risk of cardiovascular events such as spontaneous MI, unplanned urgent revascularizations, or cardiac death (Level of Evidence B-R)". |
| | |} |
| | <ref name="pmid35286170" /> |
|
| |
|
| :*The '''Cypher stent registry''', demonstrated similar benefits such as survival-free of major adverse cardiac event ''(96.4% in the SES group versus 82.8% in the BMS group; p=less than 0.05)'' and significant reduction in the rate of [[restenosis]] observed with the use of [[sirolimus|sirolimus-eluting stent]] for the treatment chronic total coronary obstruction.<ref name="pmid15172397">Hoye A, Tanabe K, Lemos PA, Aoki J, Saia F, Arampatzis C et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15172397 Significant reduction in restenosis after the use of sirolimus-eluting stents in the treatment of chronic total occlusions.] ''J Am Coll Cardiol'' 43 (11):1954-8. [http://dx.doi.org/10.1016/j.jacc.2004.01.045 DOI:10.1016/j.jacc.2004.01.045] PMID: [http://pubmed.gov/15172397 15172397]</ref> | | === Revascularization to Improve Symptoms === |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
| | |- |
| | | bgcolor="LightGreen" |"1. In patients with refractory angina despite medical therapy and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms ''[[ACC AHA guidelines classification scheme#Level of Evidence|(Level of Evidence: B-R]])'' <nowiki>"</nowiki> |
| | |} |
| | <ref name="pmid35286170" /> |
| | {| class="wikitable" style="width:80%" |
| | |- |
| | | colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) |
| | |- |
| | | bgcolor="LightCoral" |"2. In patients with angina but no anatomic or physiological criteria for revascularization, nei-ther CABG nor PCI should be performed. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD]])'' <nowiki>"</nowiki> |
| | |} |
| | <ref name="pmid35286170" /> |
|
| |
|
| *'''In patients with [[ischemia|refractory ischemia]] and severe [[LV dysfunction]] with [[EF|ejection fraction less than 35%]] may benefit from PCI in comparison to [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]].'''
| | == References == |
| | |
| :*The '''AWESOME trial and registry''', demonstrated the benefit of PCI over CABG in patients with refractory ischemia and who are at increased risk of adverse events, which may also be applicable to patients with [[left ventricular dysfunction]].<ref name="pmid10588300">Morrison DA, Sethi G, Sacks J, Grover F, Sedlis S, Esposito R et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10588300 A multicenter, randomized trial of percutaneous coronary intervention versus bypass surgery in high-risk unstable angina patients. The AWESOME (Veterans Affairs Cooperative Study #385, angina with extremely serious operative mortality evaluation) investigators from the Cooperative Studies Program of the Department of Veterans Affairs.] ''Control Clin Trials'' 20 (6):601-19. PMID: [http://pubmed.gov/10588300 10588300]</ref><ref name="pmid15219521">Sedlis SP, Ramanathan KB, Morrison DA, Sethi G, Sacks J, Henderson W et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15219521 Outcome of percutaneous coronary intervention versus coronary bypass grafting for patients with low left ventricular ejection fractions, unstable angina pectoris, and risk factors for adverse outcomes with bypass (the AWESOME Randomized Trial and Registry).] ''Am J Cardiol'' 94 (1):118-20. [http://dx.doi.org/10.1016/j.amjcard.2004.03.041 DOI:10.1016/j.amjcard.2004.03.041] PMID: [http://pubmed.gov/15219521 15219521]</ref>
| |
| | |
| :*In a '''sub-study''' of patients with prior [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]], the three-year survival rate between CABG and PCI groups did not differ significantly: 73% in the CABG group and 76% in the PCI group ''(p=NS)''. However, the '''patient choice registry''', reported that the patients with prior-CABG preferred PCI over repeat CABG.<ref name="pmid12475454">Morrison DA, Sethi G, Sacks J, Henderson WG, Grover F, Sedlis S et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12475454 Percutaneous coronary intervention versus repeat bypass surgery for patients with medically refractory myocardial ischemia: AWESOME randomized trial and registry experience with post-CABG patients.] ''J Am Coll Cardiol'' 40 (11):1951-4. PMID: [http://pubmed.gov/12475454 12475454]</ref>
| |
| | |
| *'''In patients with [[Left main|unprotected left main]] [[CAD|disease]] associated with high peri-operative risk for [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]], PCI with stent implantation may be considered as an revascularization option.'''<ref name="pmid12927190">Kelley MP, Klugherz BD, Hashemi SM, Meneveau NF, Johnston JM, Matthai WH et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12927190 One-year clinical outcomes of protected and unprotected left main coronary artery stenting.] ''Eur Heart J'' 24 (17):1554-9. PMID: [http://pubmed.gov/12927190 12927190]</ref><ref name="pmid12888147">Arampatzis CA, Lemos PA, Tanabe K, Hoye A, Degertekin M, Saia F et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12888147 Effectiveness of sirolimus-eluting stent for treatment of left main coronary artery disease.] ''Am J Cardiol'' 92 (3):327-9. PMID: [http://pubmed.gov/12888147 12888147]</ref><ref name="pmid15389236">de Lezo JS, Medina A, Pan M, Delgado A, Segura J, Pavlovic D et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15389236 Rapamycin-eluting stents for the treatment of unprotected left main coronary disease.] ''Am Heart J'' 148 (3):481-5. [http://dx.doi.org/10.1016/j.ahj.2004.03.011 DOI:10.1016/j.ahj.2004.03.011] PMID: [http://pubmed.gov/15389236 15389236]</ref>
| |
| | |
| ==Complications of percutaneous coronary intervention==
| |
| The improvements in devices, the use of stents, and aggressive antiplatelet therapy have significantly reduced the incidence of major procedural complications of PCI over the past 2 decades despite the increasing complexity of cases. However, as with any invasive procedure, complications can occur. The major complications of PTCA/PCI include coronary artery dissection and acute closure, intramural hematoma, coronary artery perforation, and occlusion of branch vessels:
| |
| Dissections are found in up to 50 percent of patients immediately after PTCA. Intimal tears or dissections following PTCA have been arbitrarily divided into types A to F.
| |
| | |
| :*Type A — Luminal haziness
| |
| | |
| :*Type B — Linear dissection
| |
|
| |
| :*Type C — Extraluminal contrast staining
| |
| | |
| :*Type D — Spiral dissection
| |
| | |
| :*Type E — Dissection with reduced flow
| |
| | |
| :*Type F — Dissection with total occlusion
| |
| | |
| These problems are now much less frequent since stent placement is performed in most percutaneous coronary procedures.
| |
| Abrupt closure is most often due to arterial dissection and is manifested as acute ischemic chest pain and ECG changes. The incidence of abrupt closure with conventional balloon angioplasty (PTCA) is approximately 5% and is associated with a 10-fold increase in mortality to about 1 percent and nonfatal MI. The frequency of this complication, however, has now been greatly reduced by pretreatment with the platelet glycoprotein IIb/IIIa receptor blockers and by the insertion of an intracoronary stent. If stenting does not restore adequate flow, emergency CABG can be performed.
| |
| | |
| Coronary artery intramural hematoma is defined as an accumulation of blood within the medial space displacing the internal elastic membrane inward and the external elastic membrane outward, with or without identifiable entry and exit points. It is identified in 6.7 percent of procedures by intravascular ultrasound (IVUS).
| |
| | |
| Coronary artery perforation in the stent era is a rare but potentially disastrous complication.
| |
| | |
| Downstream embolization of thrombus or plaque contents with microvascular obstruction is common after PCI and occlusion of side branches has been reported in up to 19 percent of cases in which a stent was placed across a major side branch.
| |
|
| |
| [[Stent thrombosis]] is catastrophic complication that usually leads to death or ST segment elevation MI. It is therefore a medical emergency. [[Stent thrombosis]] can occur acutely (during or soon after the PCI), subacutely (within 30 days after stent placement), or as a complication. Late [[stent thrombosis]] is associated with the cessation of aspirin or [[clopidogrel]] therapy. On the other hand, very late [[stent thrombosis]], occurring after one year, is associated with drug-eluting stents.
| |
| | |
| Restenosis is the result of arterial damage with subsequent neointimal tissue proliferation. It is usually defined as a greater than 50% diameter stenosis. The incidence of angiographic restenosis is approximately 30% to 40% after PTCA. Intracoronary stents reduce the rate of angiographic and clinical restenosis and post-procedural myocardial infarction compared to percutaneous transluminal coronary angioplasty (PTCA) alone. Trials have demonstrated that the sirolimus and paclitaxel drug-eluting stents markedly reduced the incidence of in-stent restenosis and the rate of target lesion revascularization compared to bare metal stents. As a result, stents are currently utilized in nearly all percutaneous coronary interventions. However, the benefits of drug-eluting stents on restenosis must be weighed against rates of stent thrombosis, which often leads to death or MI, if dual antiplatelet therapy is prematurely discontinued. Restenosis occurs more frequently in diabetics, smaller arteries, among total occlusions, and in left anterior descending arteries, particularly proximal lesions. Since not all angiographic restenosis results in recurrent symptoms, the rates of clinical restenosis are lower than these angiographic estimates. Recurrent sever angina occurs in approximately half of the patients who develop angiographic restenosis and usually responds to stenting. In symptomatic patients with BMS restenosis, a repeat stenting using a DES is usually recommended. In symptomatic patients with intracoronary DES restenosis, there are insufficient data to suggest any specific treatment.
| |
| | |
| ==Clinical trial data: PTCA/PCI versus medical treatment in the management of stable angina pectoris==
| |
| | |
| There are important limitations concerning the applicability of the results of older trials and even newer trials to the current clinical practice.
| |
| | |
| In early trials of percutaneous intervention versus medical therapy, the majority of patients underwent coronary angioplasty alone without stenting. For example, the benefits of PTCA have been compared to medical therapy in single vessel disease in the randomized Veterans Affairs Angioplasty Compared to Medicine (ACME) trial<ref>A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.
| |
| | |
| Parisi AF, Folland ED, Hartigan P.
| |
| | |
| N Engl J Med. 1992 Jan 2;326(1):10-6.
| |
| | |
| PMID: 1345754</ref>. PTCA resulted in a reduction in anginal symptoms compared to medical therapy (50% angina free versus 24% at one month), however, while the benefit of PTCA was still significant at 6 months, the magnitude of this benefit was reduced (64% angina free versus 45%). Patients treated with PTCA also had an improvement of 2.1 3.1 minutes in exercise duration which was significantly greater than the 0.5 2.2 minutes experienced in the medical therapy group.
| |
| | |
| Other older trials compared PTCA to both limited (AVERT trial) and optimal medical interventions (RITA-2 and MASS II). The findings of these trials were that patients undergoing PTCA had similar rates of death and myocardial infarction as those on medical therapy and were less likely to have angina during the first few years.
| |
| | |
| More recent literature provides comparison between the use of stents and medical management, however, there is few data examining the extensive use of drug eluting stents and current extensive antithrombotic regimens (clopidogrel and GP IIb/IIIa inhibitors). In the most recent trial, COURAGE<ref>Optimal medical therapy with or without PCI for stable coronary disease.
| |
| | |
| Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group.
| |
| | |
| N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26.
| |
| | |
| PMID: 17387127</ref>, drug-eluting stents were used in only 15 percent of patients. However, the COURAGE trial has the data most applicable to current practice. In this study 2287 patients were randomized to either aggressive medical therapy alone or aggressive medical therapy plus [[PCI]] with bare metal stenting. Patients were required to have both objective evidence of ischemia and significant CHD in a least one vessel; 87 percent were symptomatic and 58 percent had Canadian Cardiovascular Society [[CCS]] class II or III angina. Patients were excluded if they had [[CCS]] class IV angina, ≥50 percent left main disease, a markedly positive treadmill test (significant ST segment depressions and/or a hypotensive response during stage I of the Bruce protocol), an LVEF less than 30 percent, or coronary lesions deemed unsuitable for PCI. All patients received optimal medical therapy with beta blockers, calcium channel blockers, nitrates, antiplatelet therapy (either aspirin or clopidogrel), and aggressive lipid-lowering therapy with statin (attained median LDL-cholesterol was 72 mg/dL at five years). Exercise was recommended to achieve further improvements in the lipid profile when necessary. The results were published at a median follow-up of 4.6 years. There was no significant difference between the two treatment strategies for the primary end point of death from any cause and non-fatal MI. There was no significant difference in the rates of hospitalization for ACS. Patients in the PCI group underwent significantly fewer subsequent revascularization procedures (21 versus 33 percent, HR 0.60, 95% CI 0.51-71).
| |
| | |
| The issue of whether patients who receive [[PCI]] plus optimal medical therapy have a better quality of life and less angina than those who receive optimal medical therapy was addressed in COURAGE as well:
| |
| | |
| At baseline, 22 percent of patients were free of angina. At three months, significantly more patients who received PCI were angina free (53 versus 42 percent), but at 36 months there was no significant difference (59 versus 56 percent).
| |
| Patients in both groups showed significant improvements from baseline values in various measures of quality of life. The percent of patients with clinically significant improvement in parameters such as physical limitation, angina stability, angina frequency, and overall quality of life was significantly higher in the PCI group by the sixth months. However, there was no significant difference in these rates at 36 months.
| |
| | |
| The results of COURAGE demonstrate that PCI with bare metal stents plus optimal medical therapy and initial, optimal medical therapy with revascularization as necessary are comparable strategies.
| |
| | |
| ==ACC/AHA Guidelines- Revascularization With PTCA (or Other Catheter-Based Techniques) and CABG (DO NOT EDIT) <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).]''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
| |
| {{cquote|
| |
| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
| |
| '''1.''' PTCA for patients with two- or three-vessel disease with significant [[LAD|proximal left anterior descending]] [[CAD]], who have anatomy suitable for catheter-based therapy, normal LV function, and who do not have treated [[diabetes]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| |
| | |
| '''2.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with one- or two-vessel [[CAD]] without significant [[LAD|proximal left anterior descending]] [[CAD]] but with a large area of viable myocardium and [[Chronic stable angina assessing the pretest probability of coronary artery disease|high-risk criteria]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| |
| | |
| '''3.''' In patients with prior PTCA, [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] or PTCA for recurrent stenosis associated with a large area of viable myocardium and/or [[Chronic stable angina assessing the pretest probability of coronary artery disease|high-risk criteria]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| |
| | |
| '''4.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients who have not been successfully treated by [[Chronic stable angina pharmacotherapy overview|medical therapy]] and can undergo [[Chronic stable angina revascularization|revascularization]] with acceptable
| |
| risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| |
| | |
| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
| |
| '''1.''' Repeat [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with multiple saphenous vein graft stenoses, especially when there is significant stenosis of a graft supplying the [[LAD|left anterior descending]] coronary artery. PTCA may be appropriate for focal saphenous vein graft lesions or multiple stenoses in poor candidates for re-operative surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| |
| | |
| '''2.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with one- or two-vessel [[CAD]] without significant [[LAD|proximal left anterior descending]] [[CAD]] but with a moderate area of viable myocardium and demonstrable [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| |
| | |
| '''3.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with one-vessel disease with significant [[LAD|proximal left anterior descending]]0 [[CAD]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| |
| | |
| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
| |
| '''1.''' Compared with [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]], PTCA for patients with two- or three-vessel disease with significant [[LAD|proximal left anterior descending]] [[CAD]] who have anatomy suitable for catheter-based therapy and who have treated [[diabetes]] or abnormal LV function. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| |
| | |
| '''2.''' PTCA for patients with significant [[LM|left main]] [[CAD|coronary disease]] who are not candidates for [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''3.''' PTCA for patients with one- or two-vessel [[CAD]] without significant [[LAD|proximal left anterior descending]] [[CAD]] who have survived [[sudden cardiac death]] or [[Ventricular tachycardia|sustained ventricular tachycardia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
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| '''1.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with one- or two-vessel [[CAD]] without significant [[LAD|proximal left anterior descending]] [[CAD]] who have mild symptoms that are unlikely due to [[myocardial ischemia]] or have not received an adequate trial of [[Chronic stable angina pharmacotherapy overview|medical therapy]] and
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| :'''a.''' Have only a small area of viable myocardium or
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| :'''b.''' Have no demonstrable [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''2.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with borderline
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| coronary stenoses (50% to 60% diameter in locations other than the [[left main]]) and no demonstrable [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''3.''' PTCA or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with insignificant coronary stenosis (less than 50% diameter). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
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| '''4.''' PTCA in patients with significant [[left main]] [[CAD]] who are candidates for [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}}
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| ==ESC Guidelines- Revascularization to improve prognosis (DO NOT EDIT) <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367}}</ref>==
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| {{cquote|
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| ===[[European society of cardiology#Classes of Recommendations|Class IIa]]===
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| '''1.''' PCI or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|CABG]] for patients with reversible [[ischaemia]] on functional testing and evidence of frequent episodes of ischaemia during daily activities. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])''}}
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| ==ESC Guidelines- Revascularization to improve symptoms (DO NOT EDIT) <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367}}</ref>==
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| {{cquote|
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| ===[[European society of cardiology#Classes of Recommendations|Class I]]===
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| '''1.''' PCI for one-vessel disease technically suitable for percutaneous revascularization in patients with moderate-to-severe symptoms not controlled by [[Chronic stable angina pharmacotherapy overview|medical therapy]], in whom procedural risks do not outweigh potential benefits. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''
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| '''2.''' PCI for multi-vessel disease without high-risk coronary anatomy, technically suitable for percutaneous revascularization in patients with moderate-to-severe symptoms not controlled by [[Chronic stable angina pharmacotherapy overview|medical therapy]], in whom procedural risks do not outweigh potential benefits. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''
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| ===[[European society of cardiology#Classes of Recommendations|Class IIa]]===
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| '''1.''' PCI for one-vessel disease technically suitable for
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| percutaneous revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom procedural risks do not outweigh potential benefits. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''
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| '''2.''' PCI for multi-vessel disease technically suitable for percutaneous revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom procedural risks do not outweigh potential benefits. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''}}
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| ==Vote on and Suggest Revisions to the Current Guidelines==
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| *[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
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| ==Sources==
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| *The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>
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| *Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= |url=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref>
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| *TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref>
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| *The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>
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