Konservative oder invasive Therapie bei stabiler Angina pectoris?

Percutaneous coronary intervention (PCI) is effective at reducing angina in patients with symptomatic coronary artery disease and at reducing mortality in patients who have acute myocardial infarction with ST-segment elevation and in those who have high-risk acute coronary syndromes without ST-segment elevation. Such success has often been extrapolated in support of more widespread use of PCI in patients with stable coronary artery disease in hopes of reducing subsequent cardiac events. In 2004, more than one million coronary stent procedures were performed in the United States, and recent registry data indicate that approximately 85% of all PCI procedures are undertaken electively in patients with stable coronary artery disease. Whereas PCI reduces the incidents of death and myocardial infarction in patients who present with acute coronary syndromes, similar benefit has not been shown in patients with stable coronary artery disease. Whether primary intervention with PCI is the treatment of choice in patients with stable angina or not is actually under debate. (1.) Plaque-rupture and subsequent thrombosis are major causes of acute coronary syndroms. Plaque-disruption is a reflexion of inhanced inflammatory activity within the plaque. Several studies have documented that ruptured plaque and/or vulnerable plaque exist not only at the culprit lesion but also in a pan-coronary artery setting in ACS patients. Most of myocardial infarctions result from thrombosis of a lesion that by itself is not haemodynamically significant, reflecting the fact that mild/moderate lesions by far outnumber significant lesions. (2.) Assessment of the severity of coronary lesions is a major challenge in the catheterisation laboratory. The two-dimensional representation of the arterial lesion provided by angiography is limited in distinguishing intermediate lesions that require stenting from those that simply need appropriate medical therapy. Intervascular ultrasound and fractional flow reserve index provide anatomic and functional information and are promising tools to be used in the categorisation laboratory to designate patients to the most appropriate therapy. (3.) Due to technical progress and relatively low complication rates PTCA has been increasingly used in patients with stable angina without being a proven therapy based on solid scientific knowledge. This leads to enormous differencies in the number of coronary interventions per inhabitant between different regions and countries. (4.) During the past years not only interventional cardiology but also medical therapy has led to improved prognosis in patients with stable coronary disease. This positive effect may be potentiated by lifestyle intervention programmes as causal therapy for arteriosclerosis. (5.) An increasing number of prospective randomised studies and meta-analyses of such studies indicate that there is no significant advantage in regard to risk reduction with primary intervention therapy in this patients if high-risk patients are appropriately selected. Also PTCA is superior for immediate symptom relief there is no benefit with this procedures in regard to future cardiovascular events and mortality when compared with optimised medical therapy even without comprehensive lifestyle intervention. Based on an Euro Heart Survey on ambulatory patients with recent onset stable angina