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Volume 10, Supplement 2 - 2009

Volume 10, Supplement 2 - 2009

Table of Contents

Cost-Effectiveness of Alternative Approaches to the Management of Chronic Obstructive Coronary Artery Disease
Chronic obstructive coronary artery disease (CAD) is a highly prevalent condition that results in premature mortality as well as substantial morbidity due to angina and reduced quality of life. Various treatment and revascularization strategies are available for managing this condition, including medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. These treatments are expensive and, given the high prevalence of chronic CAD, there is substantial cost involved in the management of this condition. Recent clinical trials comparing percutaneous coronary intervention with medical management and/or coronary artery bypass grafting, and their associated economic analyses, have generated new information regarding the relative value of these alternative treatment strategies. In this article, we review the basic concepts of cost-effectiveness analysis and the current evidence as it relates to the cost-effectiveness of percutaneous coronary intervention in the management of chronic obstructive coronary artery disease. [Rev Cardiovasc Med. 2009;10(suppl 2):S3-S13 doi: 10.3909/ricm10S20002]
Sex Differences in Response to Treatments for Chronic Coronary Artery Disease
More women than men die of coronary artery disease (CAD) each year. In women, cardiovascular disease can present atypically and may be caused by small vessel disease rather than by major epicardial coronary luminal narrowing. Women with CAD tend to have more diffuse disease, endothelial dysfunction, and microvascular disease than men. In those studies that have looked at sex differences in treatment response, sex-specific physiologic, pharmacokinetic, and pharmacodynamic differences appear to be the cause. Women have smaller hearts, higher heart rates, shorter cardiac cycle lengths, and longer QT intervals than men. CAD medical treatments such as antiplatelet agents, anticoagulants, -blockers, and antithrombin agents may have different effects in women and men. Only 30% of percutaneous coronary interventions are performed in women. Women are less likely than men to undergo diagnostic angiography and are more likely to experience delays in treatment. [Rev Cardiovasc Med. 2009;10(suppl 2):S14-S23 doi: 10.3909/ricm10S20003]
Treatment of Left Main and Multivessel Disease in the Drug-Eluting Stent Era
For decades, the established standard of care for left main and multivessel coronary artery disease has been coronary artery bypass surgery because a significant survival advantage was found in patients revascularized with surgery compared with medical management. Although visions of less invasive strategies to manage this disease arose with the development of percutaneous coronary interventions, surgery proved to provide higher survival rates compared with balloon angioplasty and improved durability, with fewer required repeat revascularizations, compared with use of bare-metal stents. Drug-eluting stents revived hopes of an alternative treatment modality after trials demonstrated their safety and efficacy in other types of high-risk patients. Their widespread on- and off-label use led to several nonrandomized studies and, more recently, to randomized clinical trials comparing drug-eluting stents and bypass surgery. [Rev Cardiovasc Med. 2009;10(suppl 2):S24-S33 doi: 10.3909/ricm10S20004]
Interpreting the Results of the COURAGE Trial: A Non-Interventionalist Perspective
The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial was designed to determine whether percutaneous coronary intervention (PCI) coupled with optimal medical therapy (OMT) reduced the risk of death or nonfatal myocardial infarction in patients with stable coronary artery disease as compared with OMT alone. COURAGE demonstrated that an initial strategy of PCI added to OMT in these patients relieved angina to a greater extent than an initial strategy of OMT alone for a period of approximately 24 months. The initial strategy of PCI (plus OMT) did not reduce death, myocardial infarction, or other major cardiovascular events compared with OMT alone. The important quality-of-life findings permit physicians to engage in an evidence-based discussion with patients about the expected clinical and health status benefits of initial versus deferred PCI when added to OMT. [Rev Cardiovasc Med. 2009;10(suppl 2):S34-S44 doi: 10.3909/ricm10S20005]
Ischemia Is the Critical Determinant of Revascularization Benefit: An Interventionalist’s Perspective of the COURAGE Trial
Although advances in percutaneous catheter-based interventions (PCI) for coronary artery disease have been associated with reductions in angiographic as well as clinical restenosis, no consistent reduction in the occurrence of death or nonfatal myocardial infarction (MI) has been observed either between devices (balloon vs bare-metal stent vs drug-eluting stent [DES]) or between device and medically treated patients with chronic stable coronary disease. Objective evidence of myocardial ischemia—irrespective of the methodology used to demonstrate its presence—is qualitatively and quantitatively related to the occurrence of death and/or nonfatal MI. The magnitude of ischemia is directly proportional to the magnitude of revascularization benefit (reduction in death or MI). Revascularization by PCI is more effective in reducing ischemia than medical therapy alone. The evolution of both PCI technology (DES) and adjunctive pharmacology has improved the relative magnitude and durability of PCI benefit compared with medical therapy alone. [Rev Cardiovasc Med. 2009;10(suppl 2):S45-S52 doi: 10.3909/ricm10S20006]