Predictors of Medical Management in Patients Undergoing Elective Cardiac Catheterization for Chronic Ischemic Heart Disease

Abstract

Background: Compared with medical therapy, percutaneous coronary intervention (PCI) does not reduce mortality or myocardial infarction in patients with stable angina. Therefore, PCI should be guided by refractory anginal symptoms and not just lesion characteristics. Hypothesis: We hypothesized that angiographic lesion characteristics and stress test results would have a greater role in the decision to proceed with PCI than would symptom severity. Methods: We performed a retrospective cohort study of patients undergoing elective cardiac catheterization and possible PCI at an academic medical center. Anginal symptoms, optimal medical therapy, antianginal therapy, stress test results, and angiographic lesions (including American College of Cardiology/American Heart Association [ACC/AHA] lesion type) were analyzed. Logistic regression was used to determine predictors of medical management among patients not referred for coronary artery bypass surgery. Results: Of the 207 patients with obstructive lesions amenable to PCI, 163 underwent PCI and 44 were referred to medical therapy. In the multivariable logistic model, the following variables were associated with medical management: advancing age (odds ratio [OR] There was no association with sex, race, symptoms, optimal medical therapy, maximal antianginal therapy, referral status, or type of interventional cardiologist (academic vs private practice). Conclusions: For patients undergoing cardiac catheterization for stable angina, the decision to proceed to PCI vs medical management appears to depend largely on patient and angiographic characteristics, but not on symptoms or ischemia. Distal and high-risk lesions (ACC/AHA type C) are more often referred for medical therapy.

The prevalence and management of angina among patients with chronic coronary artery disease across US outpatient cardiology practices: insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study

“…Unlike patients with acute coronary syndromes (ACS), patients with chronic coronary artery disease (CAD) are predominantly managed in the outpatient setting, with therapies directed toward preventing cardiovascular events, improving survival, and controlling angina symptoms . Although the prevalence and treatment patterns for ACS are well known, data about the prevalence and management of angina among outpatients with chronic CAD are sparse . The American College of Cardiology outpatient Practice Innovation and Clinical Excellence (PINNACLE) registry (a national practice‐based cardiovascular quality‐improvement program sponsored by the National Cardiovascular Data Registry) has provided an important opportunity to better understand current treatment patterns and the opportunity to improve the outpatient management of cardiovascular diseases, particularly with respect to secondary prevention .…”

PCI for stable angina: A missed opportunity for shared decision-making

“…Atreya et al found objective evidence of this practice. 21 In a 2016 study of 207 patients with obstructive lesions amenable to PCI, the only factors associated with medical management were those that increased the risk of the procedure: age, chronic kidney disease, distal location of the lesion, and type C lesions (the most diffi cult ones to treat by PCI). More important, evidence of ischemia, presence of angina, and being on optimal medical therapy or maximal antianginal therapy were not associated with PCI.…”