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What is the role of coronary angioplasty and stenting in stable angina?

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i205 (Published 05 February 2016) Cite this as: BMJ 2016;352:i205
  1. Rasha Al-Lamee, research fellow in cardiology1,
  2. Justin Davies, consultant cardiologist1,
  3. Iqbal S Malik, consultant cardiologist2
  1. 1International Centre for Circulatory Health, NHLI, Imperial College London
  2. 2Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W2 0HS, UK
  1. Correspondence to: I Malik Iqbal.Malik{at}imperial.nhs.uk
  • Accepted 13 October 2015

What you need to know

  • First line treatment for stable CAD is optimum medical therapy to modify risk factors (for example, aspirin and statins) and relieve symptoms (for example, β blockers or calcium channel antagonists)

  • There is no evidence that PCI reduces mortality or MI rates in stable angina

  • PCI is indicated if symptoms persist despite treatment with two antianginals or if medical therapy is not tolerated, and perhaps earlier for patients with ischaemia in >10% of the left ventricle

Introduction

Stable angina refers to chest discomfort that is classically retrosternal, triggered by exertion, and relieved by rest or nitrates within minutes. Unstable symptoms, such as those occurring at rest or persisting when activity stops, suggest an acute coronary syndrome and will not be discussed here.1 More than one million people in the United Kingdom live with stable coronary artery disease (CAD), with an annual mortality rate of 1.5%.2 3 It is associated with long term morbidity and has serious effects on quality of life.4 Treatment options include medical therapy, coronary angioplasty with or without stenting (percutaneous coronary intervention; PCI), and coronary artery bypass surgery (CABG), for which guidelines from the UK’s National Institute for Health and Care Excellence (NICE) and European Society of cardiology (ESC) exist.5 6 However, patients’ and doctors’ expectations of potentials benefits of PCI in stable CAD are often overstated.7 This article focuses on the limited evidence base and indications for PCI in stable angina.

Sources and selection criteria

We searched Medline and the Cochrane Library using terms from a previous systematic review of treatment of stable angina (“stable angina”, “percutaneous coronary intervention”, and “medical therapy”),8 updated to March 2015. We also drew on our experience of coronary angioplasty and medical treatment of patients with stable coronary artery disease and our knowledge of NICE and ESC guidance.

Medical therapy

The two main goals are risk factor modification and symptomatic relief

Risk factor modification

  • Antiplatelet agents—Aspirin …

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