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Chronic Stable Angina: Evidence-Based Guide to Revascularization Khôi M. Lê, MD Desert Cardiology Center Eisenhower Medical Center Rancho Mirage, California USA Why do we treat?  To help the person live longer (reducing mortality)  To help the person live better (reducing symptoms) Standard treatment options for angina Lifestyle modifications Medications Angioplasty/stenting Bypass surgery Outline  Review selected landmark clinical trials  FAME  COURAGE  BARI 2D  MASS II  SYNTAX  Provide a framework for decision-making  Guidelines  Appropriateness criteria FAME Tonino PA et al. N Engl J Med 2009;360:213-224. Fractional flow reserve (FFR) measurements vs angiography to guide PCI decision-making Findings from FAME Tonino PA et al. N Engl J Med 2009;360:213-224. Fractional flow reserve measurements are superior to angiography in guiding decision- making regarding revascularization Treatment of nonischemic lesions led to worse clinical outcomes Kaplan-Meier Survival Curves Boden WE et al. N Engl J Med 2007;356:1503-1516 COURAGE: No difference in long-term survival, ACS, MI COURAGE: Angina-free (%) P= NS P<0.001 P=0.02 P=NS Angina relief is higher in the PCI group at 1 and 2 years, but there is also substantial improvement with medical-therapy At 5 years angina relief is equivalent Weintraub WS et al. N Engl J Med 2008;359:677-687 COURAGE: Effect of PCI on Quality of Life in Patients with Stable Coronary Disease * Indicates P<0.01 for difference between treatment groups COURAGE: Need for Subsequent Revascularization  At a median 4.6 year follow-up, 21.1% of the PCI patients required an additional revascularization, compared to 32.6% of the OMT group who required a 1 st revascularization  77 patients in the PCI group and 81 patients in the OMT group required subsequent CABG surgery  Median time to subsequent revascularization was 10.0 mo in the PCI group and 10.8 mo in the OMT group