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Controversies in Internal Medicine |

Rebuttal

Spencer B. King III, MD
Arch Intern Med. 2005;165(22):2593-2594. doi:10.1001/archinte.165.22.2593.
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Lobbying for medical or interventional therapy for chronic angina pectoris is an artificial exercise, but hopefully this discussion has been informative. Appropriately targeted secondary preventive therapy is essential for all patients with CAD. “Medical therapy vs interventional therapy,” as in the AVERT trial,1 in which effective drugs were withheld from the intervention group, should never be done again. Stent placement is never a substitute for appropriately targeted medical therapy for atherosclerosis. I have also readily admitted that PCI is not needed in all patients who receive it; however, withholding PCI in patients with angina and resorting to a formulaic stepwise “lifestyle modification” to include restriction of necessary or simply pleasurable activity is equally inappropriate if a reliable method to relieve ischemia and the resulting angina is readily available. For patients without symptoms, the bar for performing PCI should be set high and interventions limited to those conditions that do pose a significant risk. For those with effort angina, the bar need not be so high if the source or sources of ischemia can be readily detected and interventional therapy applied with a high degree of efficacy and safety. An excessively restrictive policy of a mandated trial of medical therapy before interventions are considered may impede the completion of the workup and thereby conceal high-risk features, such as left main and equivalent disease.

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