Abstract
To the Editor,
A 63-year-old woman was admitted to a local clinic for evaluation of coronary artery disease. She had no history of hypertension or diabetes. She had stable angina pectoris for the last 10 months. Her body mass index was 23 kg/m2, her blood pressure was 132/79 mmHg and her pulse was 78/min, regular. A physical examination was normal and an electrocardiogram was in normal sinus rhythm. Transthoracic echocardiography was normal and there was no wall motion abnormality. Her total cholesterol was 237 mg/dl, triglyceride 155 mg/dl, low-density lipoprotein 162 mg/dl and high-density lipoprotein 44 mg/dl. On coronary angiogram critical stenotic lesions were detected in left anterior descending, left circumflex and right coronary arteries. She was then referred to our clinic for percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) without optimal medical arrangement. After detailed examination and discussion with the patient, and considering the patient’s choice, we decided to treat the patient with intensive medication by prescribing atorvastatin (40 mg/day), metoprolol (100 mg/day), aspirin (100 mg/day), nitroglycerin and trimetazidine. Two weeks after starting the medical treatment her symptoms improved and after 4 months of treatment her symptoms resolved completely. The patient continued to use her medications and her total cholesterol reduced to 139 mg/dl, triglyceride to 110 mg/dl, low-density lipoprotein to 62 mg/dl and high-density lipoprotein increased to 45 mg/dl. Eighteen months after starting medical treatment she had atypical chest pain. Due to inadequate cardiovascular exercise testing, coronary angiography was performed. We detected significant regression in atherosclerotic plaque burden in the left anterior descending [Figure 1(a) versus Figure 1(b)], left circumflex [Figure 1(c) versus Figure 1(d)] and right coronary arteries [Figure 1(e) versus Figure 1(f)] on control angiography.
a, c and e angiographic views showing severe three vessel disease before statin treatment; b, d and f indicate the dramatic regression of vessels after eighteen months statin treatment.
Although CABG or PCI is the required and appropriate treatment modality for most patients with coronary artery disease, we believe that a thorough evaluation should be done for every patient before doing so.
The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial demonstrated that optimal medical treatment is at least as effective as PCI as an initial treatment strategy [Boden et al. 2007]. PCI or CABG does not offer important advantages over medical treatment alone in subjects with stable angina pectoris. These techniques can better be reserved for conditions for which medical treatment does not suffice or if acute coronary syndrome develops.
Studies have shown that statin therapy is effective in the regression or stabilization of coronary plaques. As in the present report, appropriate medical treatment should be offered to patients with stable angina pectoris along with intensive lipid-lowering therapy to avoid unnecessary interventions which are costly and do not always improve survival.
In the last two decades mortality from coronary artery disease declined more than 40% in the USA and approximately half of this decrease was due to improvements in medical treatment, diet and lifestyle modification whereas revascularization contributed only 7% [Ford et al. 2007]. Therefore, it is important to answer the question, why do most clinicians force patients to have PCI or CABG as an initial treatment strategy for stable angina pectoris without even offering them already proven, easily available and less costly medical treatment? Among possible answers may be because, as physicians, we prefer action to inaction and regard PCI/CABG as action and medical treatment as inaction, and we are sometimes subjective and depend more on ‘gut feelings’ than ‘book knowledge’.
In summary; it should not be overlooked that a noninvasive approach and optimal medical therapy is the alternative choice in some patients with stable angina pectoris.