More than 1 million stents are implanted annually in the United States to treat coronary disease, in the continuing hope that they are more effective than medical therapy in preventing heart attacks and prolonging life, despite abundant evidence to the contrary. Despite the highly publicized COURAGE findings, fewer than half of Americans with stable CAD who undergo stent placement have received medical therapy first. This latest meta-analysis, looking at recent PCI trials, again finds no benefit of PCI compared with medical therapy. Increasing use of American College of Cardiology Appropriate Use Criteria and realigning incentives for evidence-based approach will help improve quality of care. A “PCI first” strategy for patients with stable CAD gets a Less Is More designation because there is no known benefit and there are definite harms.
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