In this post I link to Coronary Revascularization in the United States—Patient Characteristics and Outcomes in 2020. JAMA Network Open. 2020;3(2):e1921322.
Here are excerpts:
Current indications for coronary revascularization include the relief of ischemia symptoms (ie, angina or angina equivalent) and the improvement of prognosis.1 Available evidence suggests that the prognostic and symptomatic benefits of coronary revascularization depend on the completeness of revascularization. Thus, the ability to achieve complete revascularization should be a pivotal issue when choosing the revascularization strategy.
In this issue of the JAMA Network Open, Alkhouli et al3 report the results of their nationwide representative cohort study that assessed the temporal changes in baseline characteristics of patients undergoing PCI or coronary artery bypass surgery (CABG).
The results of ISCHEMIA along with the results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE)5 and the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D)6 trials demonstrate that in patients with SIHD, revascularization does not reduce the risk of death or myocardial infarction compared with optimal medical therapy and that these patients can be effectively treated with optimal medical therapy. Furthermore, because even individuals with severe ischemia did not benefit from revascularization in ISCHEMIA, the utility of performing stress perfusion studies in those with SIHD is also called into question.
In the past decade, there has been a remarkable increase in medical therapies with proven efficacy in reducing morbidity and mortality in patients with cardiovascular diseases. These agents, which include potent antiplatelet agents, antithrombotics, high-potency statins, proprotein convertase subtilisin–kexin type 9 serine protease inhibitors, ω3 fatty acids, β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, are effective individually in reducing secondary cardiovascular events, but when prescribed together, they are even more effective and may have incremental benefits.7 However, despite the benefits of these agents, secondary preventive therapies continue to be underused, and strategies to optimize medical therapies in all individuals with cardiovascular disease are needed to optimize outcomes. If we implement such strategies, revascularization may be rarely indicated in those with SIHD.