Trends in PCI volume after negative results from the COURAGE trial

Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices?

PURPOSE OF REVIEW

For decades, the standard of care for stable ischemic heart disease (SIHD) has been an ischemia-centric approach based on largely observational data suggesting a survival benefit of revascularization in patients with moderate-or-severe ischemia. In this article, we will objectively review the evolution of the ischemia paradigm, the trial evidence comparing revascularization to medical therapy in SIHD, and what contemporary practice should be in 2022.

RECENT FINDINGS

Randomized trials, including COURAGE and, most recently, the ISCHEMIA trial, have shown no reduction in "hard outcomes" like death and myocardial infarction (MI) in SIHD compared to medical therapy. The trial excluded high-risk patients with left main disease, low ejection fraction (EF) < 35%, and severe unacceptable angina. Irrespective of the severity of ischemia and the extent of coronary artery disease (CAD), revascularization did not offer any prognostic advantage over medical therapy. On the other hand, there was a durable improvement in symptoms. While there are many caveats to the ISCHEMIA trial, the overall strengths of the trial outweigh these limitations. The findings of ISCHEMIA are consistent with previous trials. It is time for the cardiology community to pivot towards medical therapy as the initial step for most patients with SIHD. Physicians should have the "COURAGE" to embrace "ISCHEMIA" and be comfortable with treating ischemia medically.

Percutaneous Coronary Intervention Following Diagnostic Angiography by Noninterventional Versus Interventional Cardiologists: Insights From the CathPCI Registry

BACKGROUND

There are limited contemporary, national data describing diagnostic cardiac catheterization with subsequent percutaneous coronary intervention (ad hoc percutaneous coronary intervention [PCI]) performed by an invasive-diagnostic and interventional (Dx/IC) operator team versus solo interventional operator (solo-IC). Using the CathPCI Registry, this study aimed at analyzing trends and outcomes in ad hoc PCI among Dx/IC versus solo-IC operators.

METHODS

Quarterly rates (January 2012 to March 2018) of ad hoc PCI cases by Dx/IC and solo-IC operators were obtained. Odds of inhospital major adverse cardiovascular events, net adverse cardiovascular events (ie, composite major adverse cardiovascular event+bleeding), and rarely appropriate PCI were estimated using multivariable regression.

RESULTS

From 1077 sites, 1 262 948 patients were included. The number of invasive-diagnostic operators and cases performed by Dx/IC teams decreased from nearly 9% to 5% during the study period. Patients treated by Dx/IC teams were more often White and had fewer comorbidities compared with patients treated by solo-IC operators. Considerable variation existed across sites, and over two-fifths of sites had 0% ad hoc PCI performed by Dx/IC. In adjusted analyses, ad hoc performed by Dx/IC had similar risks of major adverse cardiovascular event (OR, 1.04 [95% CI, 0.97-1.11]) and net adverse cardiovascular events (OR, 0.98 [95% CI, 0.94-1.03]) compared with solo-IC. Rarely appropriate PCI, although low overall (2.1% versus 1.9%) occurred more often by Dx/IC compared with solo-IC (OR, 1.20 [95% CI, 1.13-1.26]).

CONCLUSIONS

Contemporary, nationwide data from the CathPCI Registry demonstrates the number of Dx/IC operator teams and cases has decreased but that case volume is stable among operators. Outcomes were independent of operator type, which supports current practice patterns. The finding of a higher risk of rarely appropriate PCI in Dx/IC teams should be further studied.

Contemporary Experience with Paravisceral Aortic Aneurysm (PVAAA) Repair in a Tertiary Center

OBJECTIVES

To describe contemporary outcomes from a single center capable of both complex open and endovascular aortic repair for paravisceral aortic aneurysms (PVAAA).

METHODS

Data on all patients receiving open or endovascular (endo) treatment for aortic aneurysms with proximal extent at or above the renal arteries and distal to the inferior pulmonary ligament (IPL) were reviewed. Coarsened exact matching (CEM) on age, aneurysm type, gender, coronary artery disease (CAD), previous aortic surgery and symptomatic status created balanced cohorts for outcomes comparisons.

RESULTS

Between October, 2006 and February, 2018, 194 patients were treated for juxtarenal (40%), pararenal (21%), paravisceral (6%) and Type 4 thoracoabdominal (34%) aortic aneurysms with open (81, 42%) or endo (113, 58%) at a single tertiary center. Endo repairs included renal coverage with a bifurcated graft (2%), unilateral (13%) or bilateral (4%) renal snorkels, Z-fen (15%), multi-branched graft (IDE protocol; 62%) and unique complex configurations (4%). On multivariable analysis, patients selected for open surgery were more likely to be symptomatic, whereas older patients, female patients and those with Type 4 TAAA extent were more often selected for endovascular treatment. Matching based on the significant independent covariates reduced the open and endovascular groups by one-third. Survival at 30 days was 97% for endo and 94% for open repair, 98% for both subgroups when excluding symptomatic cases, and was not different between the matched groups (98% vs 89%; P=0.23). Hospital and ICU stays were longer in open patients (8 vs. 10 days, 2 vs. 4, both P≤0.001). Post-op CVA, MI, lower extremity ischemia, surgical site infections and reoperation were not different between matched groups (all p>0.05), while pulmonary and intestinal complications, as well as grade 1/2 renal dysfunction by RIFLE criteria, were more common after open repair (all P<0.05). Spinal cord ischemia was significantly more frequent in the unmatched Endo group (11% vs. 1%, P=0.02), but this difference was not significant after matching. Composite major aortic complications was no different between treatment groups (unmatched P=0.91, matched P=0.87). Endo treatment resulted in patients more frequently discharged to home (84% vs. 66%, P=0.02). Reintervention after 30 days occurred more frequently in the endo group (P=0.002). Estimated survivals at 1 and 5 years for endo and open are 96% vs. 81% and 69% vs. 81% respectively (Log-rank P=0.57).

CONCLUSIONS

Contemporary repair of PVAAA demonstrates safe outcomes with durable survival benefit when patients are well-selected for open or complex endovascular repair. We believe these data have implications for off-label device use in the treatment of PVAAA, and that open repair remains an essential option for younger, good risk patients in experienced centers.

Physician variation in the de-adoption of ineffective statin and fibrate therapy

OBJECTIVE

To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence.

DATA SOURCES

We analyzed 2007-2015 claims data from OptumLabs^® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data.

STUDY DESIGN

We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty.

DATA EXTRACTION

We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs.

PRINCIPAL FINDINGS

Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R²  = 0.000).

CONCLUSION

On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings.

Patient and provider-level factors associated with changes in utilization of treatments in response to evidence on ineffectiveness or harm

High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI - 0.02 to - 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI - 0.15 to - 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P < 0.001), among patients seen by male providers compared to female providers (P = 0.01), and among patients seen by cardiologists compared to primary care providers (P < 0.001).

Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to "therapeutic nihilism", which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.

Lack of Transparency in Publishing Negative Clinical Trial Results

Researchers often do not publish negative results; positive outcome reported bias remains rampant. This problem is pervasive throughout the medical continuum. Failure to release less than favorable results could be construed as ethically and morally inappropriate. Failure to make public less than favorable outcomes stifles the scientific process and is contrary to the precepts of the Declaration of Helsinki and the World Health Organization. Sponsors and researchers must embrace the ideal of publishing well-designed studies with negative results.

Relationship between operator and hospital volumes and short-term mortality for percutaneous coronary intervention in New York

BACKGROUND

Recent studies have reported mixed findings regarding the inverse provider volume-outcome relationship for percutaneous coronary interventions (PCIs).

METHODS

We included patients who underwent PCIs in New York during December 2012-November 2015. Using risk-adjusted in-hospital/30-day mortality rate and appropriateness of PCI, we tested for a continuous relationship and a variety of annual PCI volume cut points at hospital and operator levels in investigating volume-outcome relationships.

RESULTS

There were 144,196 patients undergoing PCI procedures from 63 non-federal hospitals. There was a significant inverse association between risk-adjusted mortality and both annual hospital PCI volume and annual operator PCI volume. However, we did not find that there was an inverse hospital volume-outcome relationship for the 2013 ACCF/AHA/SCAI's hospital PCI volume cutoff value of 200 per year (AOR, 1.15, 95% CI, 0.88-1.51, P = 0.32) or a significant inverse operator volume-outcome relationship using the operator PCI volume cutoff value of 50 per year (AOR, 0.89, 95% CI, 0.70-1.12, P = 0.32) or for any other practical volume cutoffs. There was also no significant volume-outcome relationship for STEMI patients. Higher volume hospitals (>400) and operators (>200) tended to perform a higher percentage of inappropriate PCI procedures than their lower volume counterparts.

CONCLUSION

There were no significant PCI volume-mortality relationships for either hospitals or operators for any practical volume cuts. Higher volume hospitals and operators were associated with higher percentages of inappropriate PCIs.

Physician age and the abandonment of episiotomy

OBJECTIVE

To determine whether women treated by older physicians are more likely to undergo episiotomy.

DATA SOURCES/STUDY SETTING

Hospital discharge data from Pennsylvania for the period 1994 to 2010.

STUDY DESIGN

We examined the impact of the year in which physicians started delivering babies (a proxy for age) in Pennsylvania on episiotomy rates using a linear probability model with hospital fixed effects.

DATA COLLECTION/EXTRACTION METHODS

Using diagnosis and procedure codes, we identified women delivering vaginally (N = 1 658 327) and determined the proportion who had an episiotomy.

PRINCIPAL FINDINGS

The average physician-level episiotomy rate declined from 54 percent in 1994 to 13 percent in 2010. Rates declined among older and younger physicians, but, at any point in time, women treated by older physicians were more likely to have an episiotomy. A 10-year difference in physician age is associated with a 6 percentage point increase in episiotomy rates.

CONCLUSIONS

Results indicate that older physicians, who entered practice when episiotomy was common, were slow to adjust their practices in response to evidence showing that routine episiotomy is unnecessary.

Trends in proportions of hospitals and operators not meeting minimum percutaneous coronary intervention volume standards in Taiwan, 2001-2013

OBJECTIVE

To examine trends in proportions of hospitals and operators not meeting the minimum percutaneous coronary intervention (PCI) volume standards in Taiwan during 2001-2013.

BACKGROUND

The 2013 Clinical Competence Statement recommends that operators perform a minimum of ≥50 PCIs annually (averaged over a 2-year period) in hospitals conducting ≥200 PCIs annually.

METHODS

Taiwan National Health Insurance claims data from 2001 to 2013 are used to determine the annual numbers of PCIs performed by each hospital and operator.

RESULTS

The percentage of hospitals conducting annual PCI volumes of <200 decreased from 57% (26/46) in 2001 to 39% (29/74) in 2007 and 33% (33/91) in 2013; the percentage of operators conducting PCI volumes <50 annually remained relatively constant at 60% (146/243) in 2001, 60% (270/452) in 2007, and 58% (354/611) in 2013; and the percentage of operators conducting low volumes (<50) in low-volume hospitals (<200) decreased from 24% (57/243) in 2001 to 15% (66/452) in 2007 and 12% (76/611) in 2013.

CONCLUSIONS

Approximately one-third of hospitals and three-fifths of operators in Taiwan failed to meet minimum PCI volume standards. Further research examining patient outcomes from PCIs performed by low-volume hospitals and operators is recommended.

Outcomes of PCI in Relation to Procedural Characteristics and Operator Volumes in the United States

BACKGROUND

Professional guidelines have reduced the recommended minimum number to an average of 50 percutaneous coronary intervention (PCI) procedures performed annually by each operator. Operator volume patterns and associated outcomes since this change are unknown.

OBJECTIVES

The authors describe herein PCI operator procedure volumes; characteristics of low-, intermediate-, and high-volume operators; and the relationship between operator volume and clinical outcomes in a large, contemporary, nationwide sample.

METHODS

Using data from the National Cardiovascular Data Registry collected between July 1, 2009, and March 31, 2015, we examined operator annual PCI volume. We divided operators into low- (<50 PCIs per year), intermediate- (50 to 100 PCIs per year), and high- (>100 PCIs per year) volume groups, and determined the adjusted association between annual PCI volume and in-hospital outcomes, including mortality.

RESULTS

The median annual number of procedures performed per operator was 59; 44% of operators performed <50 PCI procedures per year. Low-volume operators more frequently performed emergency and primary PCI procedures and practiced at hospitals with lower annual PCI volumes. Unadjusted in-hospital mortality was 1.86% for low-volume operators, 1.73% for intermediate-volume operators, and 1.48% for high-volume operators. The adjusted risk of in-hospital mortality was higher for PCI procedures performed by low- and intermediate-volume operators compared with those performed by high-volume operators (adjusted odds ratio: 1.16 for low versus high; adjusted odds ratio: 1.05 for intermediate vs. high volume) as was the risk for new dialysis post PCI. No volume relationship was observed for post-PCI bleeding.

CONCLUSIONS

Many PCI operators in the United States are performing fewer than the recommended number of PCI procedures annually. Although absolute risk differences are small and may be partially explained by unmeasured differences in case mix between operators, there remains an inverse relationship between PCI operator volume and in-hospital mortality that persisted in risk-adjusted analyses.

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study

Background

The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan.

Methods

We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012.

Results

The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%.

Conclusions

In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

Statewide Hospital Discharge Data: Collection, Use, Limitations, and Improvements

OBJECTIVES

To provide an overview of statewide hospital discharge databases (HDD), including their uses in health services research and limitations, and to describe Agency for Healthcare Research and Quality (AHRQ) Enhanced State Data grants to address clinical and race-ethnicity data limitations.

PRINCIPAL FINDINGS

Almost all states have statewide HDD collected by public or private data organizations. Statewide HDD, based on the hospital claim with state variations, contain useful core variables and require minimal collection burden. AHRQ's Healthcare Cost and Utilization Project builds uniform state and national research files using statewide HDD. States, hospitals, and researchers use statewide HDD for many purposes. Illustrating researchers' use, during 2012-2014, HSR published 26 HDD-based articles on health policy, access, quality, clinical aspects of care, race-ethnicity and insurance impacts, economics, financing, and research methods. HDD have limitations affecting their use. Five AHRQ grants focused on enhancing clinical data and three grants aimed at improving race-ethnicity data.

CONCLUSION

ICD-10 implementation will significantly affect the HDD. The AHRQ grants, information technology advances, payment policy changes, and the need for outpatient information may stimulate other statewide HDD changes. To remain a mainstay of health services research, statewide HDD need to keep pace with changing user needs while minimizing collection burdens.

Prognostic value of exercise capacity in patients with coronary artery disease: the FIT (Henry Ford ExercIse Testing) project

OBJECTIVE

To examine the prognostic value of exercise capacity in patients with nonrevascularized and revascularized coronary artery disease (CAD) seen in routine clinical practice.

PATIENTS AND METHODS

We analyzed 9852 adults with known CAD (mean ± SD age, 61±12 years; 69% men [n=6836], 31% black race [n=3005]) from The Henry Ford ExercIse Testing (FIT) Project, a retrospective cohort study of patients who underwent physician-referred stress testing at a single health care system between January 1, 1991, and May 31, 2009. Patients were categorized by revascularization status (nonrevascularized, percutaneous coronary intervention [PCI], or coronary artery bypass graft [CABG] surgery) and by metabolic equivalents (METs) achieved on stress testing. Using Cox regression models, hazard ratios for mortality, myocardial infarction (MI), and downstream revascularizations were calculated after adjusting for potential confounders, including cardiac risk factors, pertinent medications, and stress testing indication.

RESULTS

There were 3824 all-cause deaths during median follow-up of 11.5 years. In addition, 1880 MIs, and 1930 revascularizations were ascertained. Each 1-MET increment in exercise capacity was associated with a hazard ratio (95% CI) of 0.87 (0.85-0.89), 0.87 (0.85-0.90), and 0.86 (0.84-0.89) for mortality; 0.98 (0.96-1.01), 0.88 (0.84-0.92), and 0.93 (0.90-0.97) for MI; and 0.94 (0.92-0.96), 0.91 (0.88-0.95), and 0.96 (0.92-0.99) for downstream revascularizations in the nonrevascularized, PCI, and CABG groups, respectively. In each MET category, the nonrevascularized group had similar mortality risk as and higher MI and downstream revascularization risk than the PCI and CABG surgery groups (P<.05).

CONCLUSION

Exercise capacity was a strong predictor of mortality, MI, and downstream revascularizations in this cohort. Furthermore, patients with similar exercise capacities had an equivalent mortality risk, irrespective of baseline revascularization status.

Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005-2009)

BACKGROUND

The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear.

METHODS AND RESULTS

Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9(th) Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457,498 PCIs were identified representing a total of 2,243,209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and secondary outcomes of procedures performed by operators in 4(th) [annual procedural volume; primary and secondary outcomes] [>100; 0.59% and 5.51%], 3(rd) [45-100; 0.87% and 6.40%], and 2(nd) quartile [16-44; 1.15% and 7.75%] were significantly less (P<0.001) when compared with those by operators in the 1(st) quartile [≤15; 1.68% and 10.91%]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization (P<0.001).

CONCLUSIONS

Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization.

Trends in percutaneous coronary intervention and angiography in Ireland, 2004-2011: Implications for Ireland and Europe

BACKGROUND/OBJECTIVES

To study temporal trends in crude and age standardised rates of cardiac catheterisation and percutaneous coronary intervention (PCI) in Ireland, 2004-2011.

METHODS

Two data sources were used: a) a survey of publicly and privately funded hospitals with cardiac catheter laboratories to obtain the annual number of procedures performed and b) anonymised data from the Hospital In-Patient Enquiry (HIPE) for angiography and PCI in acute publicly funded hospitals; age standardised rates were calculated to study trends over time.

RESULTS

From 2004 to 2011 the crude rate of angiography and PCI increased by 47.8% and 35.9% respectively, with rates of 6689 and 1825 per million population in 2011. Following age standardisation, however, PCI activity showed a non-significant decrease over time. The PCI to angiography ratio decreased from 30% to 27% and PCI was performed predominantly for stable coronary heart disease (54%) in 2011.

CONCLUSION

Angiography and PCI rates have increased in Ireland but PCI crude and age adjusted rates show divergent trends. While Ireland differs from USA and UK, with a higher proportion of PCI being performed for stable CHD in recent years, little systematic surveillance of cardiological interventions within Europe is available to benchmark improvements in Ireland.

Optimal medical therapy and percutaneous coronary intervention for stable angina: why patients should 'be taking' and 'keep taking' the tablets

WHAT IS KNOWN AND OBJECTIVE

Cardioprotective drug regimens improve outcomes in patients with stable coronary artery disease. Revascularization is recommended for the persistence of symptoms despite optimal medical therapy (OMT) or in patients likely to derive prognostic benefit. Our objective is to comment on recent evidence that initiation of OMT is suboptimal in patients undergoing percutaneous coronary intervention (PCI) but conversely adherence to medication may be higher in patients treated with PCI.

COMMENT

Large randomized controlled trials demonstrate that the risk of death or myocardial infarction is similar in patients treated by OMT alone and those treated with PCI and OMT. Despite the recommendations of international practice guidelines, OMT remains underutilized in recent analyses of patients referred for PCI. Notwithstanding the underutilization of proven therapies, a recent study suggests that adherence to medication is significantly higher in patients treated with PCI than in those treated with OMT alone. We discuss the potential factors that may contribute to underprescription of OMT and predict adherence in patients undergoing PCI.

WHAT IS NEW AND CONCLUSION

Contemporary studies continue to demonstrate underutilization of OMT in patients referred for PCI but increased medication adherence in patients treated by PCI. We argue for increased recognition of OMT as the definitive treatment for stable angina, so that we can be sure those patients who require PCI 'are taking' and 'keep taking' the tablets.