Coronary heart disease: PTCA reduces angina but leads to more CABG than medical therapy

Clinical bottom line (level 1a)

  1. Patients with non-acute coronary heart disease who undergo PTCA compared with medical therapy are less likely to suffer with angina (NNT = 13 at years) , but are more likely to require coronary artery bypass surgery (NNH = 44 at unknown) .
  2. There is no clear difference between the two groups in the rate of fatal or non-fatal myocardial infarction, death or need for PTCA.
Bucher et al: British Medical Journal 2000; 321 : 73-77
Expires Unknown Month 2003

The study

Systematic review of all randomised controlled trials of
  • Patients: non-acute coronary heart disease and no myocardial infarction within 1 week
  • Intervention: transluminal percutaneous coronary angioplasty compared with medical therapy: antiplatelet agents, beta-blockers, nitrates and calcium channel blockers.
  • Outcome: angina, non-fatal myocardial infarction, death, need for reintervention

Articles found in ?English using Medline, Embase, Cochrane database, Biological Abstracts, Health Perodical Database and PASCAL, 1979 to 1998 (search terms: transluminal percutaneous coronary angioplasty, cardiovascular agents, coronary disease and random ) and checking citatinos from relevant articles and overviews.

Selection criteria: see above
Appraisal criteria: detailed in text
Articles excluded if: 6 studies found - 953 patients treated with angioplasty, and 951 with medical therapy; followed for 6 to 57 months
Studies were found to be significantly heterogeneous for the presence of angina.

The evidence

Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
angina unknown 559/787
(71.0%)		 0.70
(0.50 to 0.98) 		13
(6 to 240)
fatal and non-fatal myocardial infarction unknown 29/951
(3.0%)		 1.42
(0.90 to 2.25) 		-82
(NNT = 28 to infinity;
NNH = 340 to infinity)
death unknown 11/951
(1.2%)		 1.32
(0.65 to 2.7) 		-270
(NNT = 250 to infinity;
NNH = 52 to infinity)
need for PTCA unknown 151/951
(15.9%)		 1.29
(0.71 to 3.36) 		-27
(NNT = 4 to infinity;
NNH = 25 to infinity)
CABG unknown 39/951
(4.1%)		 1.59
(1.09 to 2.32) 		-44
(-280 to -20)

Comments

  1. Patients undergoing PTCA only received heparin. Few had stents inserted.
  2. Only one medical trial used aggressive lipid lowering therapy.
  3. The heterogeneity noted for control of anginal symptoms could not be explained on the basis of study methodology alone, suggesting that clinical factors (such as operator experience or technique used) were important.

Citation

  1. Bucher HC, Hengstler P, Schindler C, et al: percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials. British Medical Journal 2000; 321 : 73-77
Contributor: Chris Ball, Unknown Month 2001
Reviewer:

Clinical Question.
Patient non-acute coronary heart disease
Intervention or Exposure percutaneous transluminal coronary angioplasty
Comparison medical therapy
Outcome