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Circulation. 1995;92:1676-1677

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(Circulation. 1995;92:1676-1677.)
© 1995 American Heart Association, Inc.

Articles

Coronary Angioplasty in Patients With Stable Angina Pectoris and One-Vessel Disease

Robert C. Schlant, MD

From the Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Ga.

Correspondence to Robert C. Schlant, MD, Grady Memorial Hospital, 69 Butler St, Atlanta, GA 30303.


Key Words: editorials • angioplasty • angina


*    Introduction
up arrowTop
 *Introduction
down arrowReferences
 
In this issue of Circulation, Strauss et al1 report important substudy results from the Veterans Affairs ACME study.2 The investigators of the ACME study compared the effects of coronary angioplasty (105 patients) with medical therapy (107 patients) in men who had stable angina pectoris, a positive exercise test, or a myocardial infarction within the previous 3 months who also had at least 70% to 99% stenosis of the proximal two thirds of one major epicardial coronary artery that was suitable for angioplasty. At 6 months of follow-up, all the patients had repeat exercise testing and coronary arteriography.

The study of Strauss et al1 used data from self-administered questionnaires that were completed by the participants in ACME to evaluate the benefits of percutaneous transluminal coronary angioplasty (PTCA) on the quality of life (QOL). Although some QOL data have been criticized for being relatively soft and nonobjective, it is reassuring that in the PTCA group in the ACME study there was a strong correlation between the improvement in patient scores in questionnaires designed to assess both physical functioning and psychological well-being at 6 months and the objective improvement in the percent stenosis of the index lesion in the follow-up coronary arteriogram at 6 months.1 The group of patients treated with coronary angioplasty had a greater percentage who were free of angina (64% versus 46%), a greater increase in the duration of their exercise test at 6 months (2.1 versus 0.5 minutes), and a greater improvement in angina-free time during treadmill testing.2 3

PTCA was introduced by Grüntzig et al,4 who initially used the procedure primarily in patients with one-vessel disease. Although it has long been believed that coronary angioplasty can improve patient symptoms, it has been and remains difficult to document that coronary revascularization by either surgery or PTCA produces an improvement in survival in patients with stable angina and one-vessel disease, who generally have a relatively low mortality rate.5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

The results of the study provide important data on the potential benefits of coronary angioplasty in selected patients with stable angina who have one-vessel disease and a strongly positive exercise test or myocardial infarction within 3 months. An important consideration in the management of such patients is whether the patient is satisfied with his or her QOL on medical therapy. Because it has not yet been clearly demonstrated that coronary revascularization prolongs life in such patients,5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 the primary potential benefits of PTCA include an improvement in the QOL, a decrease in medications, and improvement in functional capacity. On the downside, PTCA involves significant added expense and the possibility of myocardial infarction, death, emergency coronary artery bypass surgery, or restenosis, particularly within the first 6 months.

Ideally, the ultimate decision of whether to manage such patients with antianginal medical therapy or with angioplasty is made in consultation with the patient after a thorough discussion of the potential benefits and risks of each modality of therapy. It is, of course, of vital importance in all patients with documented coronary atherosclerosis to try to correct risk factors for atherosclerosis, including discontinuing exposure to all tobacco products and by-products and lowering the LDL cholesterol plasma levels to <100 mg/dL (2.6 mmol/L).20

In summary, this new report from the ACME study1 documents a number of QOL benefits when selected patients with stable angina pectoris are treated with coronary angioplasty rather than antianginal medical therapy. It is noteworthy that the improved QOL at 6 months was noted only in patients who had an improved coronary artery stenosis index, including six medically assigned patients who had improved angiograms. This finding helps refute the potential placebo effect of undergoing an invasive procedure.21

Whether or not the improvement in patient symptoms and functional capacity is worth the added expense, the significant risk of restenosis, particularly within 6 months, and the relatively small risks of emergency surgical revascularization, myocardial infarction, or death associated with PTCA is still not clear for many patients with stable angina pectoris. Certainly many, if not most, patients with stable angina and one-vessel disease can achieve satisfactory control of their symptoms with modern antianginal drugs and proper attention to modification of coronary risk factors.20 22 In the meantime, we await the >6-month follow-up studies in the ACME study with added evidence that successful PTCA can improve the QOL in highly selected patients with stable angina pectoris and one-vessel disease. I am sure Andreas is smiling.


*    Footnotes
 
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association, Inc.


*    References
up arrowTop
 up arrowIntroduction
 *References
 

  1. Strauss WE, Fortin T, Hartigan P, Folland ED, Parisi AF, Veterans Affairs ACME Investigators. A comparison of quality-of-life scores in patients with angina pectoris after angioplasty compared with medical therapy: outcomes of a randomized clinical trial. Circulation. 1995;90:1710-1719.
  2. Parisi AF, Folland ED, Hartigan P. A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. N Engl J Med. 1992;326:10-16. [Abstract]
  3. Hartigan PM, Parisi AF, Folland ED. Angina-free time on the treadmill: an alternative method for evaluating antianginal therapy. Am J Cardiol. 1994;73:516-518. [Medline] [Order article via Infotrieve]
  4. Grüntzig A, Senning A, Siegenthaler WE. Nonoperative dilatation of coronary artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med. 1979;301:61-68. [Abstract]
  5. European Coronary Surgery Study Group. Prospective randomized study of coronary artery bypass surgery in stable angina pectoris: a progress report on survival. Circulation. 1982;65(suppl II):II-67-II-71.
  6. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med. 1984;311:1333-1339. [Abstract]
  7. CASS Principal Investigators and Their Associates. Myocardial infarction and mortality in the Coronary Artery Surgery Study (CASS) randomized trial. N Engl J Med. 1984;310:750-758. [Abstract]
  8. Varnauskas E, European Coronary Surgery Study Group. Survival, myocardial infarction, and employment status in a prospective randomized study of coronary bypass surgery. Circulation. 1985;72:90-101.
  9. Gersh BJ, Califf RM, Loop FD, Akins CW, Pryor DB, Takaro TC. Coronary bypass surgery in chronic stable angina. Circulation. 1989;79(suppl I):I-46-I-59.
  10. Alderman EL, Bourassa MG, Cohen LS, Davis KB, Kaiser GG, Killip T, Mock MB, Pettinger M, Robertson TL. Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation. 1990;82:1629-1646. [Abstract/Free Full Text]
  11. Helfant RH. Stable angina pectoris: risk stratification and therapeutic options. Circulation. 1990;82(suppl II):II-66-II-70.
  12. Nwasokwa ON, Koss JH, Friedman GH, Grunwald AM, Bodenheimer MM. Bypass surgery for chronic stable angina: predictors of survival benefit and strategy for patient selection. Ann Intern Med. 1991;114:1035-1049.
  13. Simari RD, Bell MR, Schaff HV, Holmes DR. Percutaneous transluminal coronary angioplasty and the changing indications for coronary artery bypass grafting for single-vessel coronary artery disease. Mayo Clin Proc. 1992;67:317-322. [Medline] [Order article via Infotrieve]
  14. The VA Coronary Artery Bypass Surgery Cooperative Study Group. Eighteen-year follow-up in the Veterans Affairs Cooperative Study of Coronary Artery Bypass Surgery for Stable Angina. Circulation. 1992;86:121-130. [Abstract/Free Full Text]
  15. Berger PB, Bell MR, Garratt KN, Simari R, Holmes DR. Initial results and long-term outcome of coronary angioplasty in chronic mild angina pectoris. Am J Cardiol. 1993;71:1396-1401. [Medline] [Order article via Infotrieve]
  16. Alderman EI, Botas J. Selection of revascularization for patients with stable angina pectoris. Cor Art Dis. 1993;4:1061-1067.
  17. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, Davis K, Killip T, Passamani E, Norris R, Morris C, Mathur V, Varnauskas E, Chalmers TC. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994;344:563-570. [Medline] [Order article via Infotrieve]
  18. Mark DB, Nelson CL, Califf RM, Harrell FE, Lee KL, Jones RH, Fortin DF, Stack RS, Glower DD, Smith LR, DeLong ER, Smith PK, Reves JG, Jollis JG, Tcheng JE, Muhlbaier LH, Lowe JE, Phillips HR, Pryor DB. Continuing evolution of therapy for coronary artery disease: initial results from the era of coronary angioplasty. Circulation. 1994;89:2015-2025. [Abstract/Free Full Text]
  19. Detre K, Yeh W, Kelsey S, Williams D, Desvigne-Nickens P, Holmes D, Bourassa M, King S, Faxon D, Kent K. Has improvement in PTCA intervention affected long-term prognosis? the NHLBI PTCA Registry Experience. Circulation. 1995;91:2868-2875. [Abstract/Free Full Text]
  20. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA. 1993;269:3015-3023. [Medline] [Order article via Infotrieve]
  21. Benson H, McCallie DP. Angina pectoris and the placebo effect. N Engl J Med. 1979;300:1424-1429. [Medline] [Order article via Infotrieve]
  22. Waters D. Plaque stabilization: a mechanism for the beneficial effect of lipid-lowering therapies in angiography studies. Prog Cardiovasc Dis. 1944;37:107-120.




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