Abstract 2987: Percutaneous Coronary Intervention for Management of CAD: Evidence-Based or Enthusiasm-Bound?
Background Revascularization by percutaneous coronary intervention (PCI) is widely used in the treatment of patients with CAD. The use of PCI has exploded in the last decade with recent estimates indicating that nearly 1.4 million PCIs are performed annually in the United States alone.
Objective To perform a systemic review of the evidence in support of PCI in the management of non-acute and acute CAD.
Methods The role of PCI was assessed in three clinical settings:
comparison of PCI with medical treatment in patients with stable CAD (12 trials including COURAGE);
comparison of early invasive versus selective invasive management of unstable angina (UA)/NSTEMI (9 trials); and
comparison of PCI versus fibrinolysis for STEMI (23 trials).
The evidence for hard clinical outcomes was evaluated and a summary estimate (risk ratio, 95% CI and P values) were derived based on a random-effect meta-analysis of the randomized clinical trials. Posterior probabilities (Pr) that the risk reduction is greater than the putative threshold value for clinical importance (d>5%, 10%, 15%, and 20%), were estimated via a Bayesian analysis using an uninformative prior (mean = 0, SD=10). A survey was conducted among 65 physicians to elicit the threshold of clinically important benefit.
Results The survey yielded a clinically important median threshold of 15% relative risk reduction for death and the combined endpoint of death or MI and 20% for nonfatal MI. PCI offered statistically significant and ``clinically important” benefit in patients with STEMI, but not in patients with stable CAD or UA/NSTEMI. Although the reduction in nonfatal MI in patients with UA/NSTEMI was statistically significant in favor of PCI, the Pr of a clinically important benefit was <50%.
Conclusions PCI provides clinically important objective benefit for STEMI, but not for stable CAD or UA/NSTEMI. The justification for PCI in the latter relies only on subjective surrogates such as quality-of-life and anginal relief.