ABSTRACT
This chapter reviews the evidence base for a percutaneous approach to coronary intervention, and attempts to explain why, contrary to the recommendations of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, percutaneous coronary intervention (PCI) should be the fi rst choice for management of stable angina. Furthermore, and in the aftermath of Synergy between PCI with Taxus® and Cardiac Surgery (SYNTAX), we propose percutaneous coronary intervention as an excellent alternative for the majority of patients with left main and/or triple vessel disease. We provide a critical appraisal of both studies, showing why any conclusions should be interpreted with caution and not necessarily dictate practice. In SYNTAX, the patients received over-aggressive revascularization with an inferior stent in terms of safety and effi cacy compared to new-generation stents. COURAGE enrolled a low-risk cohort of patients with minimal anginal symptoms, and used bare metal stents in more than 95% of cases. Neither study is therefore representative of contemporary practice. We describe how, with newer stent technologies, e.g. adjunctive devices such as intravascular ultrasound and pressure wire assessment, complete and optimal revascularization can be achieved that will improve outcomes in the future.
