Major changes in the management of symptomatic obstructive coronary artery disease have been seen in the past 10 years with a substantial shift towards percutaneous coronary intervention (PCI). In the UK in 2005, for example, 73 000 PCIs were performed compared with 22 000 isolated coronary artery bypass grafting (CABG) procedures.1 Recently, there has been much debate about which of these two revascularisation options is “better” as measured by clinical outcome and overall cost effectiveness. This editorial will attempt to redress the balance on the use of PCI versus medical treatment in stable angina and its use in multivessel disease.

PCI VS MEDICAL TREATMENT IN STABLE CORONARY ARTERY DISEASE

Some have interpreted the recently published COURAGE trial,2 which randomised (after coronary angiography) 2287 patients with positive non-invasive tests to either optimal medical treatment (OMT) or PCI, as indicating that OMT is equivalent to PCI for stable coronary artery disease and suggested that PCI is an overcostly, overused procedure. The 4.6-year composite of death/non-fatal myocardial infarction was 19.0% for PCI with OMT and 18.5% for OMT alone (p = 0.62). The relevance of this study to UK practice is doubtful since angioplasty in the UK is generally reserved for patients who have continuing symptoms despite OMT, although clearly there are patients who undergo PCI where there is clear evidence on objective non-invasive testing of silent ischaemia and a significant lesion in the same territory.

It has never been the interventionist’s claim that PCI has an impact on mortality. Given that patients with left main stem disease and important left ventricular dysfunction (the very patients who may benefit prognostically from revascularisation) were excluded from this trial it seems highly likely that a similar trial comparing CABG with OMT would also show no difference. It is important to note that >40% of patients had little or no angina at trial entry. At follow-up 32.6% …