NEJM Clinical Pearls / 200710/25
PCI versus Medical Management for Stable Angina
The results of the recent Clinical outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial raises questions about using PCI over optimal medical therapy regarding the composite end point of death or myocardial infarction. However, angina symptoms were significantly reduced with the use of PCI, a phenomenon that has been reported in multiple clinical trials. However, there is no evidence that PCI in patients with stable angina is more effective than optimal medical management in reducing mortality.
PCI versus CABG
The addition of CABG to medical therapy in recent randomized trials does appear to extend the survival of patients with advanced, multifocal coronary artery disease, such as three-vessel disease. If a patient has two-vessel coronary artery disease, without involvement of the proximal left anterior descending coronary artery, then PCI may be preferable as compared to CABG. If a drug-eluting stent is placed during PCI to reduce the risks of restenosis and repeat revascularization, then the patient will need dual antiplatelet therapy (aspirin plus clopidogrel) for at least 1 year and perhaps indefinitely.
Morning Report Question
Q: What is a contraindication to the use of metformin?
A: Safe use of metformin requires normal renal function. In fact, any degree of renal insufficiency is a contraindication for metformin use. Metformin is not recommended if the creatinine is >1.5 mg per deciliter in a man or >1.4 mg per deciliter in a woman.