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LETTER TO THE EDITOR
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 36-37

Management of asymptomatic coronary artery disease


Consultant Physician, High Born Poly Clinic, Kalaburagi, Karnataka, India

Date of Submission03-Dec-2019
Date of Acceptance04-Dec-2019
Date of Web Publication14-Jan-2020

Correspondence Address:
Swetha Amaresh Biradar
H.No 72, Visveswerayya Nagar, Sedam Road, Kalaburagi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_83_19

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How to cite this article:
Biradar SA. Management of asymptomatic coronary artery disease. APIK J Int Med 2020;8:36-7

How to cite this URL:
Biradar SA. Management of asymptomatic coronary artery disease. APIK J Int Med [serial online] 2020 [cited 2020 Mar 28];8:36-7. Available from: http://www.ajim.in/text.asp?2020/8/1/36/275990



Respected Editor,

A case report published in October to December issue (doi: 10.4103/AJIM_41_19) about “Asymptomatic triple vessel coronary artery disease: A treatment dilemma”[1] discusses management issues in asymptomatic coronary artery disease (CAD). The case mentioned was a diabetic and hypertensive and had triple-vessel disease with significant left main stenosis on coronary angiogram. He was subjected to coronary artery bypass graft (CABG) surgery. The author has discussed the dilemma in treating such asymptomatic patients.

The recently published ISCHEMIA trial [2] addresses this issue. The study done by Hochman failed to show that routine invasive therapy was associated with a reduction in major adverse ischemic events compared with optimal medical therapy among stable patients with moderate ischemia.

In this randomized parallel trial, the patients with stable CAD and moderate-to-severe ischemia were randomized to routine invasive therapy (n = 2588) versus medical therapy (n = 2591). In the routine invasive therapy group, patients underwent coronary angiography (CAG) and percutaneous intervention (PCI) or CABG as appropriate. In the medical therapy group, patients underwent CAG only for failure of medical therapy. 34% had no angina, 44% had several times per month, and only 22% had angina daily or weekly.

The primary outcome of cardiovascular death, myocardial infarction (MI), resuscitated cardiac arrest, or hospitalization for unstable angina or heart failure at 3.3 years occurred in 13.3% of the routine invasive group compared with 15.5% of the medical therapy group (P = 0.34). The findings were same in subgroups.

The authors concluded that among patients with stable CAD and moderate-to-severe ischemia on noninvasive stress testing, routine invasive therapy failed to reduce major adverse cardiac events compared with optimal medical therapy. It is important to note that patients with >50% left main stenosis, recent MI, advanced chronic kidney disease, left ventricular ejection fraction <35%, unacceptable angina at baseline NYHA Class III–IV heart failure, prior PCI, or CABG within the last year were excluded.

The case mentioned with significant left main disease is not a candidate for routine medical therapy (excluded in ISCHEMIA trial) and rightly had undergone revascularization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Premnath M. Asymptomatic triple vessel disease coronary artery disease. APIK J Int Med 2019;7:137-40.  Back to cited text no. 1
    
2.
Hochman JS. International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA). Philadelphia PA: AHA; 2019.  Back to cited text no. 2
    




 

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