Clinical Practice and Outcomes in Angina

Results from two presentations on outcomes in the management of stable and unstable angina and chest pain at the American Heart Association Scientific Sessions 2009.

In “Recent Changes in the Practice of Elective PCI for Stable Angina,” Dauerman and colleagues looked at the effect on clinical practice of the 2007 publication of results from the COURAGE trial, which reported “outcomes at 4.6 years for stable angina patientsundergoing PCI versus optimal medical management.” Researchers looked at data from more than 10,000 consecutive patients from the NorthernNew England Cardiovascular Disease PCI Registry who underwentPCI between January 2007 and June 2008, and “compared changeover time in the number of stable angina patients undergoingPCI by 3-month time periods” (beginning with Q1 2007, when COURAGE was published). For the purposes of this study, patients with stable angina were defined as patients who underwent “an electivePCI as an outpatient or within 24 hours of admission, who wereasymptomatic or had chronic stable angina.” Researchers also compared the change over time for patients who underwent PCI for indications other than stable angina. The authors reported that 1,511 patients underwent PCI for stable angina, and 8,783 did so for other indications. Compared to Q1 2007, in Q2 2007, “there was an immediate 13% decrease” in the percent of stable anginapatients undergoing PCI. The percent of patients who underwent PCI continued to decrease, with a slight reversal of this decline starting in Q1 2008. The percent of patients who underwent PCI for other indications remained relatively stable over this time period. These results led the authors to conclude that “publication ofthe COURAGE trial was temporally associated with a significantand sustained decrease in the utilization of PCI to treat StableAngina.”

In “Routine vs. Selective Invasive Management and Clinical Outcomes in Non-ST-Segment Elevation Myocardial Infarction or Unstable Angina: A Meta-analysis of Large Randomized Controlled Trials (RCTs),” Pinninti and colleagues examined the evidence base for the use of early routine invasive strategy (RIS) for acute coronarysyndromes (ACS). Noting that some of the trials that provided the clinical basis of the evidence for current ACC/AHA treatment guidelines were small or not optimally blinded, the researchers “sought to evaluate the benefits and risks of RISversus a selective invasive strategy (SIS) on short-and long-termclinical outcomes (death or MI) in the treatment of ACS by conductinga meta-analysis of all RCTs with at least 100 patients in eacharm.” The authors conducted a search of the literature, selecting six randomized controlled trials (RCTs) that enrolled 10,081 patients (5,037 treated via RIS, 5,043 via SIS). The authors found a similar incidence of death and MI among patients treated via RIS or SIS. Death and MI were more common for RIS patients during index hospitalization. RIS patients experienced a decrease in post-discharge death and MI. The authors concluded that although “there is late clinical benefit associatedwith” early RIS as compared with SIS in ACS patients, this “salutary effect may be partiallyoffset by an early hazard of increased in-hospital death orMI. Such a risk-benefit assessment should be carefully consideredin all ACS patients.”