Revascularization versus medical treatments in stable coronary artery disease: predicting the future of novel drug therapies for stable angina.

Over the past 2 decades, drug therapy of patients with stable angina pectoris has improved, with a marked impact on the hard clinical outcomes of mortality and myocardial infarction. In contrast, recent trials have not demonstrated beneficial effects of revascularization on mortality. However, in the large trials that compared medical treatment with percutaneous coronary intervention (PCI) or surgery, high-risk patients, such as those with severe 3-vessel disease with or without left ventricular dysfunction, were excluded. In the COURAGE and FAME 2 trials, the only difference between the PCI and medical therapy groups was a higher rate of revascularization in the latter. Similar findings were made in studies comparing medical treatment with coronary surgery. New pharmacological approaches are being developed to further delay the progression of atherosclerosis. These include new lipid-lowering drugs acting in concert with statins (cholesteryl ester transfer protein inhibitors, proprotein convertase subtilisin/kexin type 9 inhibitors), aldosterone antagonists, colchicine, methotrexate, and interleukin-1 inhibitors. In conclusion, from the available data, PCI and coronary surgery have not been shown to improve hard end points and routine use of invasive revascularization should be avoided in patients with chronic stable angina. Evidence-based secondary prevention remains the most important approach.