Nonemergent Percutaneous Coronary Intervention Versus Optimal Medical Treatment for Stable Ischemic Heart Disease: A Rapid Response Literature Review
Authors: McCausland Rachel , Fontanarosa Joann , Patel Ravi 
Published: August 2023

Aims. There is uncertainty around the optimal role of percutaneous coronary intervention (PCI) for management of chronic coronary syndrome, specifically when patients have disease in multiple coronary vessels and disease in the proximal portion of the left anterior descending coronary artery. This uncertainty was reflected in 2021 guidance from the American College of Cardiology (ACC)/American Heart Association (AHA) on coronary artery revascularization. The Agency for Healthcare Research and Quality has commissioned this rapid response literature review to meet a Congressional request for a summary of recent evidence on the benefits of angioplasties conducted in nonemergency situations. Methods. This rapid response literature review on the comparative effectiveness of nonemergent PCI followed established best systematic review methods, modified to meet a shortened project timeframe. We searched PubMed®, Embase®, and the Trip© medical database from 2018 through April 2023 for systematic reviews (SRs), clinical practice guidelines, and randomized controlled trials, and summarized the evidence comparing PCI to optimal medical therapy (OMT) for stable ischemic heart disease (SIHD). Our primary outcomes of interest were major objective cardiovascular outcomes, including mortality, myocardial infarction, stroke, urgent revascularization, or composites of one or more of these hard clinical outcomes. Where available, we also abstracted patient reported outcomes (e.g., angina severity and quality of life [QoL]) from included studies. Findings. Key findings from nine SRs and one primary study include: • The body of evidence directly comparing PCI to OMT for SIHD has remained largely unchanged since the 2021 ACC/AHA guidance’s publication. • Most studies of revascularization for coronary artery disease do not focus on direct head-to-head comparisons of PCI versus OMT for SIHD but instead either (1) compare OMT to invasive revascularization (PCI and coronary artery bypass graft [CABG] combined cohort); (2) compare PCI to CABG; or (3) compare different PCI techniques. • Another factor that complicates comparison is that the meta-analyses often included data from CABG and PCI combined cohorts (e.g., the recent landmark ISCHEMIA trial) but reported the outcomes as PCI specific. • In the general SIHD population, our review did not find evidence to support survival benefit or effect on hard clinical outcomes when PCI is added to OMT. • Limited evidence indicates there may be a beneficial effect of PCI on angina symptoms and measures of QoL, but most systematic reviews focused on major objective cardiovascular outcomes and did not consider QoL or freedom from angina. • Both OMT and PCI have evolved significantly during the period of time in which the systematic reviews’ included studies were conducted. It is not clear how these changes may have affected the applicability of past studies to current practice. Conclusions. The evidence directly comparing PCI to OMT for SIHD has remained largely unchanged since publication of the 2021 ACC/AHA guidelines. More research is needed to verify the comparative effectiveness of nonemergent PCI compared to medical treatment for individuals with SIHD, and how the effectiveness varies by certain patient populations and clinical presentation.