We would like to commend Drs Eyuboglu and Kucuk for their thought-provoking letter. We entirely agree that medical therapy is of paramount importance in the treatment of patients with stable angina and, indeed, all of the patients in our study,1 irrespective of type of stent/scaffold implanted, were treated with optimal medical therapy (OMT) consisting of dual antiplatelet therapy, a high-dose statin, beta-blocker, and an angiotensin converting-enzyme inhibitor or angiotensin receptor blocker, unless contraindicated. Other anti-anginal agents, such as long-acting nitrates, nicorandil, ranolazine, and calcium channel blockers, were considered when residual small vessel or diffuse disease were present.
We should, however, stress that the field of coronary intervention has advanced considerably from the times of the COURAGE trial.2
Patients selected in the COURAGE trial were mainly those with intermediate stenosis (70% or more) and myocardial ischemia (exercise or pharmacologic vasodilator stress) or at least 80% stenosis with classic angina. Patients with very tight stenoses, who derive the most benefit from percutaneous coronary intervention (PCI),3 were most likely excluded on the basis of a markedly positive stress test, one of the exclusion criteria. Of interest, drug-eluting stents, the new generation of which has been associated with improved survival,4 were only used in 2.7% of patients in the PCI group because they were approved in the last 6 months of the trial.
In current times, most coronary interventional cardiologists treat intermediate coronary lesions in stable angina patients only if they can prove that they are hemodynamically significant, either with an invasive (pressure wire) or a noninvasive functional test. This practice partially stems from the results of the FAME II trial,5 which revealed a significant reduction in urgent revascularization in the PCI (4%) vs the OMT group (16.3%) even though the investigators found no significant differences in all-cause mortality (PCI vs OMT: 1.3% vs 1.8%, 0.58) or myocardial infarction (5.8% vs 6.8%, P<.56). Furthermore, most centers use contemporary new generation drug-eluting stents; in a network meta-analysis of 93 553 patients in 100 randomized controlled trials,4 these stents were associated with reduced mortality (everolimus: 0.75, 0.59 to 0.96; zotarolimus [Resolute]: 0.65, 0.42-1.00) compared with medical therapy alone. Of note, this mortality benefit was not seen in patients treated with plain balloon angioplasty (0.85, 0.68-1.04), bare metal stents (0.92, 0.79-1.05), mainly used in COURAGE, or early generation drug-eluting stents (paclitaxel: 0.92, 0.75-1.12; sirolimus: 0.91, 0.75-1.10; zotarolimus [Endeavor]: 0.88, 0.69-1.10).
In summary, we agree that in stable angina patients the verdict is still out as to whether PCI adds a mortality benefit over and above OMT; however, there seem to be some signs that this may be the case with newer stent platforms. Our study suggests that patients on OMT treated with overlapping first generation bioresorbable scaffolds have similar 1-year outcomes to those treated with overlapping new generation everolimus-eluting stents, despite the latter being the leading force in coronary intervention.