An Open (Up the Vessel) and Shut (Up the Critics) Case or Fake News?

Abstract

Percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) has made tremendous strides over the past several decades. On the one hand, the diversity and complexity of lesions treatable with PCI has increased significantly. At the same time, our understanding of the appropriateness of PCI in SIHD has been refined with the results of trials, such as COURAGE (Optimal Medical Therapy with or without PCI for Stable Coronary Disease), ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina), FAME (Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention), and ISCHEMIA (Initial Invasive or Conservative Strategy for Stable Coronary Disease). Overall, PCI along with optimal medical therapy (OMT) appears to result in significant improvements in anginal symptoms compared with OMT alone. At ≈5 years of followup, PCI for SIHD does not lower mortality. The effect on myocardial infarction (MI) appears to be neutral: a longterm reduction in nonprocedural MI is balanced by a higher risk of periprocedural MI, although the prognostic implications of the 2 are likely different.1 Patients with chronic total occlusion (CTO) of a coronary artery present a challenging and somewhat enigmatic subset of patients with SIHD. Although CTOs are highly prevalent among patients with SIHD, CTO PCI was typically excluded from these landmark trials. Furthermore, these patients typically have a higher burden of comorbidities and are at higher risk of future cardiac events compared with similar patients with nonCTO SIHD.2,3 In addition, there are significant technical complexities and lower success rates with CTO PCI compared with nonCTO PCI, with success rates only recently improving in the setting of technological advances and operator skill set (75%– 80% earlier, now ≈90%– 95%). In addition, procedural complication rates remain higher than for nonCTO PCI.3– 5