Current indications for percutaneous coronary intervention for chronic stable angina: implications of the COURAGE Trial.

Patients presenting with symptoms of chronic stable angina represent a relatively significant portion of general population, especially among older aged. Among people 45-54 years old, stable angina is reported between 2-5% in men and 0.5-1% in women, while among people 65-74 years old the corresponding incidence is reported 11-20% for men and 10-14% for women respectively. In >50% of these patients angina limits significantly everyday activities leading to premature retirement, according to various national health and insurance surveys. Chronic stable angina is a slowly progressive disease and the patients show a relative mortality of approximately 2% per year, significantly lower than the mortality of patients with unstable acute coronary syndromes or vascular disease and only slightly higher than that of patients with several risk factors who are under treatment for primary prevention. Mortality among patients with stable angina is related to the extension and the severity of coronary artery disease (CAD), their left ventricular function, exercise capacity, nature of the symptoms and ECG findings both at rest and during stress. The main objectives of the treatment of patients with chronic stable angina, as outlined in the current guidelines, are directed towards preventing myocardial infarction and death (thereby improving the “quantity” of life) as well as preventing further ischemia and related symptoms (thereby improving “quality” of life) [1]. Current stable angina treatment includes medical therapy, percutaneous coronary revascularization procedures (PCI) and surgical revascularization (CABG). A meta-analysis of six randomized trials of percutaneous coronary revascularization with plain old balloon angioplasty (POBA) showed that, compared to medical treatment, POBA offered more symptomatic relief in patients with stable angina, without any significant difference in the rate of death, acute MI or need for new PCI. There was only a trend for more CABG procedures among patients treated with POBA and this was attributed to an excess of ischemic complications [2]. It must be mentioned that recent technical advances such as stents or newer devices that could improve the efficacy of POBA and abolish this excess have not been used in these trials. In another meta-analysis [3] of 11 randomized trials of PCI with implantation of bare metal stents (BMS), treatment of patients with stable angina by PCI showed no difference in death, acute myocardial infarction (MI), CABG or PCI procedures compared to medical treatment. Common finding in all these trials is that PCI shows no difference in death or MI compared to medical therapy, but a clear and sustained benefit in angina relief. As it is underscored also in MASS II trial results, neither PCI AtHENs cArDIOLOGY UPDAtE 2008