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People with stable coronary artery disease need drugs first, not stents

BMJ 2007; 334 doi: (Published 05 April 2007) Cite this as: BMJ 2007;334:716

People with stable coronary heart disease have little if anything to gain from initial treatment with percutaneous coronary intervention (PCI), researchers reported last week. Those treated with the best available drug and lifestyle regimen did just as well in a large randomised trial as those who had the same regimen plus angioplasty and stenting (mostly bare metal). Death rates and other cardiovascular events were closely matched during a median follow-up of 4.6 years. A comparable proportion of patients in each group reached the main composite end point of death or non-fatal myocardial infarction (19% v 18.5%; hazard ratio for the PCI group 1.05, 95% CI 0.87 to 1.27). Angina improved for patients in both groups, but the initial improvement was greater for those who had PCI.

Most Americans who have PCI have stable coronary artery disease. So these findings if widely accepted could signal a substantial change in practice, says a linked editorial (doi: 10.1056/NEJMe078036). Aggressive control of risk factors and serum lipids combined with antiplatelet treatment, β blockers, and other recommended drugs is an effective initial strategy that has now been tested in more than 5000 patients. PCI can be deferred safely for most. About a third of the patients in the medical therapy group eventually needed revascularisation in this trial.


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