STABLE CORONARY ARTERY DISEASE

Question 1

This trial enrolled patients with stable coronary artery disease (CAD) and significant coronary stenosis, comparing optimal medical therapy alone versus percutaneous coronary intervention (PCI) plus optimal medical therapy. The trial demonstrated that there was no significant difference in the risk of death, myocardial infarction, or other major cardiovascular events between the two treatment groups over a median follow-up of 4.6 years. This challenged the notion that PCI offered significant additional benefits beyond optimal medical therapy in patients with stable CAD.

Answer 1

COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation)

Question 2

This trial compared the outcomes of coronary artery bypass grafting (CABG) and PCI in patients with multivessel CAD. The trial showed that CABG was associated with better long-term outcomes, including lower rates of death, myocardial infarction, and need for repeat revascularization, compared to PCI. This highlighted the superiority of CABG over PCI in patients with more extensive CAD.

Answer 2

BARI trial (Bypass Angioplasty Revascularization Investigation):

Question 3

This trial compared the outcomes of PCI guided by fractional flow reserve (FFR) measurement versus angiography alone in patients with multivessel CAD. FFR-guided PCI was found to reduce the risk of major adverse cardiovascular events and the need for repeat revascularization compared to angiography-guided PCI. This emphasized the importance of physiologic assessment in guiding revascularization decisions in patients with complex CAD.

Answer 3

FAME trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation)

Question 4

This trial evaluated the efficacy of PCI versus placebo in patients with stable angina and single-vessel CAD. The trial found that PCI did not significantly improve exercise time or angina frequency compared to a sham procedure. This challenged the widespread use of PCI for stable angina and highlighted the importance of placebo-controlled trials in assessing the true effectiveness of interventions.

Answer 4

ORBITA trial (Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina)

Question 5

This trial ompared the outcomes of PCI and CABG in patients with complex CAD, including left main and/or three-vessel disease. The trial demonstrated that CABG was associated with better outcomes, particularly in patients with more complex coronary anatomy. This influenced guidelines and clinical practice, emphasizing the role of CABG as the preferred revascularization strategy in patients with complex CAD.

Answer 5

SYNTAX trial (SYNergy between percutaneous coronary intervention with TAXUS and cardiac surgery)

Question 6

This trial evaluated the impact of CABG on mortality and cardiovascular outcomes in patients with ischemic cardiomyopathy. The trial showed a survival benefit with CABG compared to medical therapy alone, particularly in patients with significant coronary artery disease. This supported the use of CABG as a treatment strategy to improve outcomes in patients with ischemic cardiomyopathy.

Answer 6

STICH trial (Surgical Treatment for Ischemic Heart Failure)

Question 7

This trial investigated the optimal management strategy for patients with stable CAD and moderate-to-severe ischemia. The trial compared an invasive strategy (PCI or CABG) with optimal medical therapy alone and found no significant reduction in the risk of death or major cardiovascular events with the invasive approach. This challenged the routine use of revascularization in stable CAD and highlighted the importance of optimal medical therapy.

Answer 7

ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches)

Question 8

This trial compared the outcomes of PCI and CABG in diabetic patients with multivessel CAD. The trial demonstrated that CABG was superior to PCI in reducing major adverse cardiovascular events, highlighting the importance of CABG as the preferred revascularization strategy in diabetic patients with complex CAD.

Answer 8

FREEDOM trial (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease)

Question 9

This trial evaluated treatment strategies in diabetic patients with stable CAD. The trial found no significant reduction in the risk of death or major cardiovascular events with prompt revascularization plus intensive medical therapy compared to intensive medical therapy alone. This emphasized the importance of aggressive medical therapy in managing stable CAD in diabetic patients.

Answer 9

BARI 2D trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes)

Question 10

This trial compared the outcomes of PCI and CABG in real-world practice. The trial found no significant difference in long-term mortality between the two revascularization strategies, providing important real-world evidence to guide treatment decisions.

Answer 10

ASCERT trial (The American College of Cardiology Foundation–The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies)

Question 11

This trial compared the outcomes of PCI with drug-eluting stents versus CABG in patients with left main CAD. The trial showed that PCI with drug-eluting stents was non-inferior to CABG in terms of the composite endpoint of death, myocardial infarction, or stroke at 1 year, suggesting that PCI could be considered as an alternative to CABG in select patients with left main CAD.

Answer 11

PRECOMBAT trial (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease)

Question 12

This trial evaluated the role of nuclear imaging in guiding revascularization decisions in patients with stable CAD. The findings suggested that adding nuclear imaging to standard care did not improve outcomes compared to standard care alone, highlighting the importance of evidence-based decision-making in the management of stable CAD.

Answer 12

COURAGE nuclear substudy

Question 13

This trial compared FFR-guided PCI plus medical therapy versus medical therapy alone in patients with stable CAD. The trial showed that FFR-guided PCI reduced the risk of urgent revascularization compared to medical therapy alone, providing evidence to support the use of physiologic assessment in guiding revascularization decisions in stable CAD.

Answer 13

FAME 2 trial (Fractional Flow Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease)

Question 14

This substudy of the COURAGE trial assessed the role of stress echocardiography in guiding revascularization decisions in patients with stable CAD. The findings suggested no significant difference in outcomes between PCI plus optimal medical therapy and optimal medical therapy alone when guided by stress echocardiography, highlighting the need for careful consideration of individual patient factors in treatment planning.

Answer 14

COURAGE echocardiography substudy

Question 14

This study compared the efficacy and safety of high-dose atorvastatin versus usual-dose pravastatin in patients with stable CAD. The trial showed that high-dose atorvastatin significantly reduced the risk of major cardiovascular events compared to usual-dose pravastatin, highlighting the importance of intensive statin therapy in the management of stable CAD.

Answer 14

TIMI 18 trial (Thrombolysis in Myocardial Infarction 18)

Question 15

This trial compared the efficacy of amlodipine, enalapril, and placebo in reducing cardiovascular events in patients with stable CAD. The trial demonstrated that amlodipine, a calcium channel blocker, reduced the risk of cardiovascular events compared to placebo, providing evidence for the use of calcium channel blockers in the management of stable CAD

Answer 15

CAMELOT trial (Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis)

Question 16

This trial evaluated the efficacy of perindopril, an angiotensin-converting enzyme (ACE) inhibitor, in reducing cardiovascular events in patients with stable CAD. The trial showed that perindopril significantly reduced the risk of cardiovascular events compared to placebo, highlighting the cardioprotective effects of ACE inhibitors in this patient population.

Answer 16

EUROPA trial (European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease)

Question 17

This trial investigated the efficacy of ramipril, an ACE inhibitor, in reducing cardiovascular events in high-risk patients, including those with stable CAD. The trial demonstrated that ramipril significantly reduced the risk of cardiovascular events compared to placebo, providing further support for the use of ACE inhibitors in the management of stable CAD.

Answer 17

HOPE trial (Heart Outcomes Prevention Evaluation)

Question 18

This trial investigated the use of a novel index, called the instantaneous wave-free ratio (iFR), to guide PCI in patients with stable CAD. The trial showed that iFR-guided PCI was non-inferior to FFR-guided PCI in terms of major adverse cardiovascular events at 1 year, suggesting that iFR could be an alternative physiologic assessment tool for guiding revascularization decisions in stable CAD.

Answer 18

DEFINE-FLAIR trial (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularization)

Question 18

This trial compared outcomes of PCI guided by fractional flow reserve (FFR) versus angiography alone in patients with stable CAD. The trial demonstrated that FFR-guided PCI significantly reduced the risk of major adverse cardiovascular events compared to angiography-guided PCI, providing further evidence for the use of physiologic assessment in guiding revascularization decisions in stable CAD.

Answer 18

FAME 3 trial (Fractional Flow Reserve Versus Angiography-Guided Management to Optimize Outcomes)