Percutaneous Coronary Intervention and the Various Coronary Artery Disease Syndromes

Abstract

Percutaneous techniques have become the dominant revascularization strategy for the treatment of patients with both acute and chronic coronary artery disease. They have been studied in multiple registries and randomized clinical trials using as comparators medical therapy and coronary bypass graft surgery. The studies comparing PCI versus medical therapy have emphasized several important issues. First and foremost is that optimal therapy should be the cornerstone for all patients with coronary artery disease. Neither PCI nor CABG should be offered in place of optimal medial therapy but always layered on top of it. The second issue that has been repeatedly identified is that PCI is excellent for the relief of ischemia in carefully selected patients. In patients with mild stable angina and only mild and demonstrable ischemia, optimal medial therapy should be used as the first option. In this setting, PCI can be very valuable in improving symptoms and reducing ischemia. In patients with acute ischemic syndromes such as STEMI, PCI should be the dominant strategy and has been documented to result in improved outcome compared with lytic therapy. It has become the standard of care when it can be performed by experienced operators in experienced centers in a timely fashion. Systems of care have evolved to optimize prompt transfer of these patients to PCI capable hospitals. The studies comparing PCI versus CABG have been typically performed in patients with more extensive disease and ischemia. In this setting, there is documented benefit in terms of symptomatic improvement but also in selected patients, improved survival. The importance of certain baseline characteristics, e.g. diabetes mellitus and the extent and severity of CAD using scores such as the SYNTAX score have come to occupy a central position in decision making. Patients with the most extensive disease benefit more from CABG; with less extensive disease there is equipoise between PCI and CABG.