? What more will it take to turn the tide of treatment for angina patients from a PCI-first to an optimal medical therapy– first approach? 1

Background & objectives  Early randomized trials of percutaneous intervention (PCI) vs medical therapy alone and some meta-analyses demonstrated greater reduction in angina with PCI than with medical therapy alone.  However, prior meta-analyses were based on PCI and medical therapy that do not reflect current interventional practice.  Meta-analysis of contemporary trials has been performed to compare initial coronary stent implantation and medical therapy vs medical therapy alone to determine the effect on death, nonfatal myocardial infarction, and persistent angina. 2

Stergiopoulos and Brown. Arch Intern Med. 2012;172(4): Effect of initial stent implantation vs medical management for nonfatal myocardial infarction non fatal MI Meta-analysis of eight contemporary trials (7229 patients, 4.3 years follow-up)

Stergiopoulos and Brown. Arch Intern Med. 2012;172(4): Effect of initial stent implantation vs medical management for persistent angina during follow-up Meta-analysis of eight contemporary trials (7229 patients, 4.3 years follow -up)

Implantation of a stent for the treatment of stable coronary artery disease (CAD) does not lower the risk of death, nor does PCI reduce the risk of nonfatal MI or angina when compared with optimal medical therapy. The failure of stent implantation to reduce the risk of death or MI compared with medical therapy reinforces current concepts of the underlying pathophysiologic characteristics of atherosclerosis as a diffuse process leading to vulnerable plaque disruption and subsequent coronary thrombosis, MI, and death. The findings support recommendations that stable CAD patients should be treated with medical therapy rather than first undergoing stent implantation. Implications