Percutaneus Coronary Intervention

(PCI) vs
Optimal Medication Therapy
in Coronary Artery Disease (CAD)

dr. Nurul Rahayu Ningrum, Sp.JP, FIHA, FESC

 The Definition and Prevalence

ANGINA
is chest pain or discomfort caused when your
heart muscle doesn't get enough oxygen-rich
blood during exercise or stress multiple “faces” syndrome44

~112 millions of people

have Angina

4-5% Prevalence of Angina

Angina affects 1.6% world population and is associated with

reduced QoL1,2

1. Vos T et al. Lancet 2012:380; 2163-96 2. Benjamin EJ, et al. Circulation 2017:135;e146-e603 3. Beltrame JF, et al. http://cdn.intechopen.com/pdfs-wm/32288.pdf . Accessed on October 8,
2014. 4. Ambrosio G et al. Angiology 2019:70(5):397-406
Economical impact of Angina

ECONOMICAL & PERSONAL

BURDEN
Higher risk of

x3 x1.5 x4
DISABILI JOB LOSS2 DEPRESSIO
TY1 N1

>50% DECREASED IN QUALITY OF

LIFE1

1. Jespersen L et al. Clin Res Cardiol. 2013;102:571-581. 2. Padala SK et al. J Cardiavascular Pharmacol Ther. 2017;22(6):499-510. 3. Vos T et al. Lancet 2012; 380: 2163–96;
However, Angina is still underestimated

Monthly Angina CADENCE Trial: 2,031 Weekly Angina

patients with stable angina

48%

Daily Angina

80% 37%

Consider as being optimally controlled

Beltrame JF, et al. Arch Intern Med. 2009;169(16):1491-1499

Sequence of Events in Ischemic Heart Disease

• Arrythmias
• Lost of muscle
• Angina MI
• Silent Ischemia
Remodeling

CAD
Progresif dilatation

Endothelial dysfunction
Heart Failure
Death
Risk Factor
 Acute coronary syndrome
 Unstable angina

 Acute non ST-elevation myocardial infarction

 Acute ST-elevation myocardial infarction

 Chronic coronary artery disease

 Chronic stable angina
 DEFINITION CAD

It develops It used to refer

when the to symptoms of Global Burden of
arteries of the Often caused by angina pectoris
the build up of Disease Study
heart cannot which can stable (2020)
deliver enough plaque, inside or unstable, also
the lining of reported that
oxygen-rich can become prevalence of IHD
blood to the larger coronary acute coronary
arteries. was 1.72% (126
heart. syndrome. million) worldwide
with 9 millions
deaths

NHLBI. 2019. Coronary Heart Disease

 TYPE OF
REVASCULARIZATIO
N

 Percutaneus Coronary
Intervention / PCI
 Coronary Artery
Bypass Grafting /CABG

Neumann FJ et al. 2018 ESC/EACTS Guidelines on myocardial Revascularization.

2019; 40, 87–165
Observed cardiac death rates over the follow-up period in
patients undergoing revascularization (Revasc) vs medical
therapy (Medical Rx) as a function of the amount of inducible
ischemia.
 Con’t
In the setting of no or mild amounts of inducible ischemia, patients
undergoing medical therapy had a survival advantage over patients
undergoing revascularization
In patients undergoing medical therapy, predicted mortality increased
significantly as a function of % myocardium ischemic
But in revascularized patients, mortality rates did not increase
 Log hazard ratio for revascularization (Revasc) vs medical therapy
(Medical Rx) as a function of % myocardium ischemic based on final Cox
proportional hazards model.
 Con’t
 Demonstrated that pts with extensive CAD preferentially
benefited from revascularization whereas pts with small
amounts of disease did not
 The strength of the present study is the finding that one does
not need to know the extent of angiographic CAD to predict
benefit, only the extent of ischemia, a marker available
noninvasively and earlier
• Discussion

The addition of PCI to OMT resulted in more

01 effective reduction of ischemia than OMT alone.

For PCI + OMT patients, the greater reduction in ischemic burden was
02 associated with improvements in angina class and less reliance on nitrate
therapy for symptom relief.

Treatment targets of >5% ischemia reduction or elimination of residual ischemia are

03 therapeutic goals that should be tested in a randomized clinical trial, especially in patients
with moderate to severe ischemia at baseline.
 Take Home Message

Patient with angina Extensive CAD benefited

should be holistically from revascularization
assessed, so we can whereas other with
define the severity of small amounts of
ischemia. disease did not.

Optimal medical Adding PCI to OMT

therapy with or resulted in greater
without reduction in ischemia
revascularization is a compared with OMT
must. alone.
Thank you