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Percutaneous coronary revascularisation: is it ever worth what it costs?

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“How could percutaneous coronary intervention without the risks and morbidities of heart surgery not be of benefit to patients? Hard experience teaches that such attractive “pathophysiological” simplifications are unreliable guides to practice and paradoxically may lead to worse rather than better treatment decisions”

See also article on page 1238 and viewpoint on page 1188

Thirty years ago, Andreas Gruentzig changed the course of medical history when he reported his initial clinical experience with percutaneous coronary intervention (PCI) using balloon catheters. Currently, cardiologists in the UK perform over 70 000 PCI procedures a year, which represents about a 400% increase in volume over the past decade.1 Similar increases can be found in many European countries and in the USA.2 Although US doctors perform about 10 times as many procedures as their UK counterparts on a population five times as large, both groups behave as if an ever increasing number of patients with coronary artery disease (CAD) are best served by undergoing PCI. From these observations, and given the growing financial investment implied by the trends, one might conclude that a broad consensus exists about the clinical role of PCI.

The evidence base, however, does not provide the strong support implied by these international practice trends. For example, a recent meta-analysis comparing PCI with conservative medical treatment in 2950 patients from 11 clinical trials found no benefit of intervention on hard cardiac event rates, including death or myocardial infarction (MI).3 Further, none of the many trials comparing bare metal stents with balloon-only PCI, and more recently, drug-eluting stents with bare metal stents, provides reason to believe that these technological improvements in the PCI procedure have delivered measurable improvements in hard cardiac event rates.4 5 Only restenosis rates (which reflect procedure-induced complications rather than disease-related complications) have clearly been reduced …

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  • Conflict of interest:

    Consulting: All <10k

    Aventis, Bridgewater, New Jersey, USA

    AstraZeneca, London, UK

    Medtronic, Inc., Minneapolis, Minnesota, USA

    Novartis, East Hanover, New Jersey, USA

    Research Grants: All >10k

    National Institutes of Health/National Heart, Lung, and Blood Institute

    National Institutes of Health/Agency for Healthcare Research and Quality

    Proctor & Gamble, Cincinnati, Ohio, USA

    Pfizer, New York City, New York, USA

    Medtronic, Inc., Minneapolis, Minnesota, USA

    Alexion Pharmaceuticals, Inc., Cheshire, Connecticut, USA

    Medicure, Winnipeg, Manitoba, Canada

    Miscellaneous: >10k

    Mosby, St. Louis, Missouri, USA, American Heart Journal Editor

  • Abbreviations:
    acute coronary syndrome(s)
    coronary artery disease
    myocardial infarction
    percutaneous coronary intervention, QALY, quality-adjusted life year

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