Original title: Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: A collaborative meta-analysis of contemporary randomized clinical trials. Reference: Stergiopoulos K el al. JAMA Intern Med 2013; DOI:10.1001/jamainternmed.2013

The amount in ischemic patients with stable coronary heart disease is associated with poor prognosis. However, it is unclear whether revascularization to reduce that amount also reduces ischemic events compared with medical treatment.

This meta- analysis included major works that randomized patients with stable coronary artery disease and demonstrated ischemia  to revascularization or medical treatment (MASS II , COURAGE , BARI 2D , FAME 2, etc.) . A total of 4064 patients, all with documented ischemia by stress test, gamma camera, echo stress or fractional flow reserve were analyzed. The endpoints included in the analysis were death from any cause, nonfatal myocardial infarction, urgent revascularization and angina. With a median follow-up of 5 years,  mortality rate from all causes was observed in the group receiving revascularization by angioplasty  versus  those who only received medical treatment  6.5 % and 7.3 % respectively (OR 0.90 CI 95% 0.71 to 1.16; p= ns) , nonfatal myocardial infarction 9.2 % and 7.6% (OR 1.24 CI 95% 0.99 to 1.56; p=ns) , urgent revascularization 18.3 % and  28.4 % (OR 0.64, CI 95% 0.35 to 1.17) and angina 20.3 % and 23.3 % (OR 0.91, CI 95% 0.57 to 1.44).

Conclusion:

In patients with stable coronary artery disease and documented ischemia, percutaneous revascularization does not seem to reduce events compared with medical treatment alone.

Editorial comment

This work, like all meta-analyzes, drag the limitations of the studies in which it was based. For example, ischemia was documented in all patients but as a binary variable. If we know that the greater ischemia increased mortality, why not also expect a different benefit with revascularization according to the amount. The same should be considered for symptoms; to worse major functional class a greater relief should be by revascularization. Finally the localization of the ischemic territory is taken into account in daily practice but has been difficult to differentiate in the works and should be taken into consideration. Perhaps some of these questions can be answered by the 8000 patients that ISCHEMIA study plans to include. 

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