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Is it difficult to defend revascularization with stable CAD?
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Revascularization has a role to play.
If a patient has symptoms of angina that cannot be well-controlled with medical therapy or if a patient is intolerant to maximal medical therapy, prompt revascularization can significantly improve symptoms and quality of life. That is, after all, the main goal of medicine. In a patient whose initial symptoms are well-controlled with medical therapy, it is reasonable to defer revascularization as long as the patient is followed closely for new or worsening angina symptoms or worsening ischemia, at which point revascularization would be appropriate.
It would be a mistake to interpret BARI 2D and say there is no role for revascularization in stable disease because there certainly is. In BARI 2D, a good proportion (42%) of patients in the medical therapy arm ultimately underwent revascularization.
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It is reasonable to try all stable patients with aggressive medical therapy and lifestyle modification on first encounter and see how they do with that. If symptoms do not escalate and ischemia is well controlled, then it would be reasonable to defer revascularization. This strategy is consistent with American College of Cardiology and American Heart Association guidelines for revascularization of stable patients.
Whether patients with very high-risk features (significant proximal three-vessel disease, marked left ventricular dysfunction, prior MI) benefit from routine revascularization on top of contemporary, optimal medical therapy is an important question that randomized clinical trials need to answer.
Patients are not static and things change — so it is critical to follow patients very closely if revascularization is initially deferred.
Deepak L. Bhatt, MD, MPH, is Chief of Cardiology at VA Boston Healthcare System and Director of the Integrated Interventional Cardiovascular Program at Brigham and Women’s Hospital and VA Boston.
Medical therapy is the cornerstone of treatment.
We have three treatment options, and it would be wrong to say that we should abandon revascularization totally in favor of optimal medical therapy. The BARI 2D data strongly support that, for the majority of patients with stable CAD and diabetes, optimal medical therapy out of the gate is an appropriate and defendable initial treatment approach.
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There will be, however, patients who do not respond to medical therapy or whose quality of life is not improved or who have worsening ischemia or advancing CAD. For those who either fail medical therapy or have persistent symptoms, clearly revascularization would be appropriate.
The new wrinkle in BARI 2D is that CABG surgery seems to trump medical therapy in patients with more extensive CAD and ischemia.
Until two or three years ago, we had a sort of pejorative view of optimal medical therapy – it seemed old fashioned or passé, certainly not as high-tech or appealing to physicians as angioplasty or stenting. Yet, here we see two large trials published in the last two years (BARI 2D and COURAGE) comprising more than 4,500 patients showing convincingly that medical therapy has evolved dramatically over the last decade.
We have drugs that we did not have 10 years ago that modify diabetes and CAD. While it may, in fact, seem ho-hum and mundane to advocate optimal medical therapy, it is clearly a very important approach to management and should be the cornerstone of treatment. The BARI 2D results amplify that.
William E. Boden, MD, is Professor of Medicine and Public Health at University of Buffalo, Chief of Cardiology at Buffalo General Hospital and Millard Fillmore Hospital and Study Chair of the COURAGE trial.