Long-term prognosis in stable angina; medical treatment or coronary revascularization in patients younger than 70years?

Background: Literature on the appropriateness of coronary revascularization in chronic angina is still scanty. The study aimed to compare long-term effects of revascularization with those of medical therapy in stable angina. Methods: In an observational single center study, we assessed 10 year follow-up of 1442 consecutive patients with chronic angina, at least one coronary vessel disease, no previous myocardial infarction, screened for inducible ischemia. Patients > 70 years were excluded. The event-free probabilities were estimated by Kaplan-Meier curves; all cause death, cardiac death, non-fatal myocardial infarction were the considered end points. Results: Age was 56 +/- 8 yrs. Global left ventricular function was preserved in all. Myocardial ischemia was documented in 1190 patients. Coronary disease was more severe in patients with inducible ischemia as compared to those with negative stress test (p < 0.001); 868 patients underwent one revascularization procedure, 511 coronary angioplasty. Median follow-up was 106 months; 13% all cause deaths, 8% cardiac deaths, 6% non-fatal myocardial infarction were registered. When provocative test was negative revascularization did not improve survival (1% per year mortality irrespective of type of treatment). Conversely survival was significantly improved by revascularization when ischemia was documented (0.7% vs 1.8% per year mortality for revascularization vs medical therapy, p < 0.05). Incidence of non-fatal myocardial infarction was low and similar in both groups. Conclusion: In low-risk chronic angina coronary revascularization does not improve long-term prognosis unless inducible myocardial ischemia is present. This suggests considering coronary revascularization as an effective tool in treating coronary artery disease only when myocardial ischemia has been documented.