Stents, Surgery, and Medical Therapy: Will Knowledge Trickle Down?

Larry Husten a Contributor at Forbes has an excellent review “Stents Lose In Comparisons With Surgery And Medical Therapy“. He takes a look at two new meta-analyses in JAMA Internal Medicine looking at alternatives to stents percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). 

The first of the two papers by Sipahi and colleagues did a meta-analysis of six RCT comparing PCI and CABG in patients with multivessel disease. 

With an average 4.1 years of followup, CABG was associated with significant reductions in total mortality, myocardial infarction, repeat revascularization and the rate of major adverse cardiovascular and cerebrovascular events (MACCE). CABG was also associated with a trend for excess strokes.

Here are the risk ratios for CABG:

Mortality: 0.73, CI 0.62-0.86, p<0.001
MI: 0.58, CI 0.48-0.72, p<0.001
Stroke: 1.36, CI 0.99-1.86, p=0.06
Repeat revascularization: 0.29, CI 0.21-0.41, p<0.001
MACCE: 0.61, CI 0.54-0.68, p<0.001

As noted the authors concluded that “CABG should be the preferred revascularization method for most patients with multi vessel coronary artery disease.”

second paper by Kathleen Stergiopoulos and colleagues looked at studies comparing medical therapy with PCI in >4,000 patients with stable coronary artery disease and documented ischemia and a five year median follow-up there were no significant difference in death, nonfatal MI, unplanned revascularization, or angina. 

“Finally,” the authors write, “these findings call into question the common practice of ischemia-guided revascularization (either using noninvasive testing techniques or FFR) where the presence of myocardial ischemia routinely determines patient selection for coronary angiography and revascularization.”

So we have a changing landscape in the world of stents, CABG, and medical therapy based on an excellent set of studies looking at the current available data. As Husten closes his article with PCI is “a cornerstone of daily practice in evaluation of patients with CAD and endorsed by the American College of Cardiology Foundation AHA and European Society of Cardiology guidelines”. 

Data is pointing a different direction regarding the management of ischemia guided revascularization. Do patients have to wait years until prospective studies are completed to show that this meta analysis was accurate? Will patients with CAD know enough or have enough time to find this data and ask their cardiologist about stents vs. CABG or medical therapy? Will cardiologists step up and present this data to their patients? Is this a case of trickle down knowledge where the gate keepers are the one’s performing the work?

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