Contemporary randomised trials of percutaneous coronary intervention (PCI) in chronic coronary syndrome (CCS) demonstrate no difference between patients treated with a conservative or invasive strategy with respect to all-cause mortality or myocardial infarction, although trials lack power to test for individual endpoints and long-term follow-up data are needed. Open-label trials consistently show greater improvement in symptoms and quality of life among patients with stable angina treated with PCI. Further studies are awaited to clarify this finding. In patients with severe left ventricular (LV) systolic dysfunction and obstructive coronary artery disease in the Revascularization for Ischemic Ventricular Dysfunction trial, PCI has not been found to improve all-cause mortality, heart failure hospitalisation or recovery of LV function when compared with medical therapy. PCI was, however, performed without additional hazard and so remains a treatment option when there are favourable patient characteristics. The majority of patients reported no angina, and the low burden of angina in many of the randomised PCI trials is a widely cited limitation. Despite contentious evidence, elective PCI for CCS continues to play a significant role in UK clinical practice. While PCI for urgent indications has more than doubled since 2006, the rate of elective PCI remains unchanged. PCI remains an important strategy when symptoms are not well controlled, and we should maximise its value with appropriate patient selection. In this review, we provide a framework to assist in critical interpretation of findings from most recent trials and meta-analysis evidence.
- Percutaneous Coronary Intervention
- Angina Pectoris
- Coronary Angiography
- Coronary Artery Disease
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Twitter @timcartlidge1, @VijayKunadian
Contributors TC, MK and GW wrote the first draft and undertook multiple revisions. TC, MK, EPN and GW provided critical review. VK conceived the idea and undertook multiple revisions.
Funding VK received research funding from the British Heart Foundation (CS/15/7/31679). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. EPN reports research grants from Abbott and Amgen and lecture fees/honoraria from Amgen, AstraZeneca, Bayer, Pfizer and Sanofi-Regeneron outside the submitted work. GW received speaker honoraria for Abbott Vascular, ASAHI Intecc, Orbus-Neich, Philips, Siemens, Shockwave Medical and Terumo.
Competing interests VK is an associate editor for Heart.
Provenance and peer review Commissioned; externally peer reviewed.