Angioplasty for treatment of coronary artery disease - Tips from Other Journals

Date: June, 1992

Percutaneous transluminal coronary angioplasty was performed 200,000 times in the United States in 1990. The procedure is a cost-effective alternative to bypass surgery in patients with moderate to severe angina and suitable coronary anatomy. In addition, it is increasingly being used as primary therapy in patients with mild and well-controlled angina and single-vessel disease. However, few studies have assessed whether it offers any advantages over drug therapy in this population. Parisi and colleagues compared the results of angioplasty and medical therapy in patients with mild, stable angina, 70 to 90 percent stenosis of one epicardial coronary artery and exercise-induced myocardial ischemia.

The study included 212 patients. A total of 107 patients were randomly assigned to drug therapy according to a stepped-care approach designed to eliminate angina. The remaining patients were assigned to angioplasty and underwent the procedure within three days of randomization.

Eighty patients who underwent angioplasty had a clinically successful procedure, with an initial mean reduction in stenosis from 76 percent to 36 percent. Two patients who underwent angioplasty required emergency by pass surgery.

During the six-month follow-up period, five patients in the angioplasty group had a myocardial infarction. Five bypass operations and 19 repeat angioplasty procedures for restenosis were necessary in patients who underwent angioplasty. One death and three myocardial infarctions occurred in the medically treated gourp. In this group, 11 angioplasty procedures were performed.

Twice as many patients in the angioplasty group were symptom-free at one month. At six months, 64 percent of the angioplasty group and 46 percent of the medical therapy group were free of angina. The total exercise time and the maximal duration of angina-free exercise were significantly longer in patients treated with angioplasty.

The authors conclude that percutaneous transluminal coronary angioplasty is more effective than medical therapy in immediately relieving anginal symptoms and improving exercise tolerance. It also reduces the need for antianginal medication. However, agioplasty is more expensive than medical management and is associated with a small immediate risk of acute myocardial infarction, acute coronary occlusion leading to bypass surgery and a later need for redilation because of restenosis.

In an accompanying editorial, Baim indicates that further improvements in short- and long-term outcomes are necessary before percutaneous transluminal coronary angioplasty can be considered as primary therapy for patients with mild, stable angina. (New England Journal of Medicine, January 2, 1992, vol. 326, pp. 10, 56.)

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