PERCUTANEOUS CORONARY INTERVENTION VS OPTIMAL MEDICAL THERAPY IN STABLE ISCHEMIC HEART DISEASE: LONG-TERM SURVIVAL AND QOL. A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

It remains unclear whether percutaneous coronary intervention (PCI) is superior to optimal medical therapy (OMT) in terms of long-term survival in stable ischemic heart disease (SIHD). Symptom relief with PCI has been demonstrated in major randomized trials, however, the trials have varied in their survival benefits.

Objective:

To compare long-term all-cause mortality, events of major adverse cardiovascular events (MACE) and patient reported quality of life (QoL) between PCI and OMT in SIHD.

Methodology:

A systematic search was carried out for randomized controlled trials comparing PCI with OMT directly. Six trials were included, namely COURAGE, ISCHEMIA, FAME 2, BARI 2D, MASS II, and RITA-2. Extracted outcomes were all-cause mortality, composite cardiovascular endpoints and QoL measures (SAQ, RAND-36, SF-36, and Angina class and exercise tolerance). Due to the variability in outcome definition, a random effects model was applied for mortality and MACE, and results for QoL were reported narratively to maintain the accuracy of the data.

Results:

In the 6 trials and follow-up periods of 2.7 to 10 years, none of the studies showed a statistically significant decrease in long-term all-cause mortality with PCI compared with OMT. COURAGE (19.0% vs 18.5%), ISCHEMIA (6.5% vs 6.4%), BARI 2D (11.7% vs 12.2%), MASS II (approximately 75% vs 69% 10-year survival for PCI vs MT with no significant PCI - MT difference) and RITA-2 (8.5% vs 8.7% at 7 years) all reported no mortality advantage with an initial PCI strategy. FAME 2 demonstrated a reduced number of primary composite events with PCI, but this result was explained more by urgent revascularization, with no significant difference between groups for death and myocardial infarction.

QoL results showed a consistent pattern for COURAGE, ISCHEMIA, MASS II and RITA-2, with PCI resulting in greater improvement in the early stages (3-12 months) in frequency of angina, physical limitation and disease-specific QoL. In ISCHEMIA, in particular, early gains were strongest among those patients who had frequent baseline angina. Longer follow up, QoL differences were lessened, reflecting optimization of OMT and cross-over revascularization in medically treated patients.

Conclusion:

From the evidence obtained from only six major randomized trials, PCI is not superior to OMT for long-term survival in stable ischemic heart disease. Its main benefit is more and quicker early relief of symptoms whereas in the long term, qualities of life tend to converge between strategies. These findings provide support for an individualized approach in the treatment of SIHD with early PCI reserved for patients with significant angina or functional limitation and a primary goal of idealizing the role of OMT alone in providing long-term survival.