Optimal Medical Therapy with or without PCI for Stable Coronary Disease

Boden, William E.; O’Rourke, Robert A.; Teo, Koon; Hartigan, Pamela; Maron, David J.; Kostuk, William J.; Knudtson, Merril L.; Dada, Marcin; Casperson, Paul; Harris, Crystal L.; Chaitman, Bernard R.; Shaw, Leslee J.; Gosselin, Gilbert; Nawaz, Shah; Title, Lawrence M.; Gau, Gerald T.; Blaustein, Alvin S.; Booth, David C.; Bates, Eric R.; Spertus, John A.; Berman, Daniel S.; Mancini, G.B. John; Weintraub, William S.

doi:10.1056/nejmoa070829

Cited by 4,072 publications

(2,170 citation statements)

References 44 publications

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“…Despite these guidelines for management of stable obstructive CAD, previous work from our group and others has demonstrated that OMT is underused in this patient population 1, 2, 14, 16. In contrast, there are no definitive guidelines for medical management of nonobstructive CAD, and there is substantial uncertainty as to what constitutes OMT in a population of patients with nonobstructive CAD.…”

Section: Discussionmentioning

confidence: 96%

“…There are clear guidelines for medical management of stable obstructive CAD, which include aspirin, ACE‐I, or ARB in appropriate patients, an anti‐ischemic agent, and statins 14. Despite these guidelines for management of stable obstructive CAD, previous work from our group and others has demonstrated that OMT is underused in this patient population 1, 2, 14, 16.…”

Section: Discussionmentioning

confidence: 99%

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Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

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BackgroundThere is a paucity of data on the need for optimal medical therapy (OMT) in nonobstructive coronary artery disease . We sought to understand if there was variation in the use of OMT between hospitals for patients with nonobstructive coronary artery disease, the factors associated with such variation, and its clinical consequences.Methods and ResultsUsing a population‐level clinical registry in Ontario, Canada, we identified all patients >66 years undergoing coronary angiography for the indication of stable angina, who had nonobstructive coronary artery disease between November 1, 2010, and October 31, 2013. Hierarchical multivariable logistic models were developed to identify the factors associated with OMT use, with median odds ratio used to quantify the degree of variation between hospitals not explained by the modeled risk factors. Clinical outcomes of interest were all‐cause mortality and rehospitalization, with follow‐up until March 31, 2015. Our cohort consisted of 5413 patients, of whom 2554 (47.2%) were receiving OMT within 1 year. There was a 2‐fold variation in OMT across hospitals (30.4%–61.8%). The variation between hospitals was fully explained by preangiography medication use (median odds ratio of 1.21 in the null model and 1.03 in the full model). There was no difference in risk‐adjusted mortality (hazard ratio, 0.94; 95% confidence interval, 0.76–1.16); however, patients receiving OMT had a lower risk of all‐cause hospital readmission (hazard ratio, 0.89; 95% confidence interval, 0.84–0.95).ConclusionsThere is wide variation in the use of OMT in patients with nonobstructive coronary artery disease, the major driver of which is differences in baseline medication use.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

View full text Add to dashboard Cite

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“…The seminal study by Gould et al reported that hyperemic flow begins to decline in the presence of stenosis with a reduction in diameter larger than 50% 1. This cut‐off value has been used for the threshold of inducible ischemia; therefore, it is accepted as the gold standard for guiding revascularization, validating noninvasive testing, and evaluating outcomes after revascularization strategies 2, 3, 4. However, cumulative evidence suggests that angiographically determined anatomical stenosis severity often underestimates or overestimates the functional significance of lesions 5, 6, 7.…”

Section: Introductionmentioning

confidence: 99%

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Yonetsu

Murai

Kanaji

et al. 2017

JAHA

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BackgroundDespite a moderate correlation between angiographical stenosis and physiological significance, the mechanism of discordance has not been fully elucidated, particularly regarding the significance of microvascular function. This study sought to clarify whether microvascular function affects visual‐functional mismatch between quantitative coronary angiography (QCA) and fractional flow reserve (FFR).Methods and ResultsWe assessed QCA, FFR, coronary flow reserve, and the index of microcirculatory resistance in 849 non‐left‐main coronary lesions with visually estimated intermediate stenoses from 532 patients. Clinical and lesion‐specific characteristics and physiological parameters associated with mismatch and reverse mismatch were studied. Coronary flow reserve and index of microcirculatory resistance showed a weak, but significant, correlation with FFR (R=0.306, P<0.001 and R=0.158, P<0.001, respectively). Four hundred twenty‐two lesions were visually nonsignificant (diameter stenosis assessed by QCA [QCA‐DS] ≤50%) and 427 lesions were visually significant (QCA‐DS >50%). Among visually nonsignificant lesions, FFR ≤0.80 (reverse mismatch) was observed in 129 lesions (30.6%). Among visually significant lesions, FFR >0.80 (mismatch) were observed in 179 lesions (41.9%). The significant predictors of reverse mismatch were male sex, nonculprit lesions of acute coronary syndrome, left anterior descending artery location, smaller QCA reference diameter, greater QCA‐DS, lower coronary flow reserve, and lower index of microcirculatory resistance. Mismatch was associated with right coronary artery location, greater QCA reference diameter, smaller QCA‐DS, lesion length, higher coronary flow reserve, and higher index of microcirculatory resistance.ConclusionsThere was a high prevalence of visual‐functional mismatches between QCA and FFR. The discrepancy was related to clinical characteristics, lesion‐specific factors, and microvascular resistance that was undistinguishable by coronary angiography, thus suggesting the importance of physiological lesion assessment.

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“…The resultant reduction in intracellular Na + concentration inhibits partially the Na + /Ca ++ exchange current, preventing the deleterious effect of intracellular Ca ++ overload under the trigger of ischemia. This indirect decrease in intracellular Ca ++ concentration is responsible for the well‐documented antianginal effect of ranolazine 11, 12. In the field of clinical studies, ranolazine is presented as an effective, well‐tolerated, and safe drug, in patients with coronary artery disease and residual reversible ischemia 13, 14.…”

Section: Discussionmentioning

confidence: 99%

Ranolazine: safe and effective in a patient with hypertensive cardiomyopathy and multiple episodes of electrical storm

Margos

Mokadem

et al. 2017

Clinical Case Reports

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Key Clinical MessageAmong implantable cardioverter‐defibrillator (ICD) recipients, there are patients with recurrent episodes of electrical storm (ES), retractable to the optimal antiarrhythmic drug therapy or invasive ablation procedures. A relatively novel anti‐ischemic drug with also antiarrhythmic properties, ranolazine, may effectively suppress ventricular arrhythmias in such patients for a long period of time.

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Optimal Medical Therapy with or without PCI for Stable Coronary Disease

Abstract: As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number, NCT00007657 [ClinicalTrials.gov].).

Cited by 4,072 publications

References 44 publications

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

Ranolazine: safe and effective in a patient with hypertensive cardiomyopathy and multiple episodes of electrical storm

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