Percutaneous Transluminal Coronary Angioplasty Versus Medical Therapy for Stable Angin Pectoris: Outcomes for Patients With Double-Vessel Versus Single-Vessel Coronary Artery Disease in Veterans Affairs Cooperative Randomized Trial

Objectives. This study sought to assess outcomes of men with double-vessel coronary artery disease randomly assigned to treatment by percutaneous transluminal coronary angioplasty (PTCA) or medical therapy, compared with previously reported outcomes for men with single-vessel disease. Background. We previously reported that PTC provides better symptom relief and treadmill performance than medical therapy for men with stable angin pectoris due to single-vessel disease. Whether this advantage applies to patients with double-vessel disease is unknown. Methods. Male patients (n = 328) with stable angin pectoris and ischemi on treadmill testing were randomly assigned to PTC or medical therapy; 101 patients had double-vessel disease, and 227 had single-vessel disease. Symptoms, treadmill performance, quality of life score, coronary stenosis and myocardial perfusion were compared at baseline and at 6 months. Patients were followed up for up to 6 years and underwent additional treadmill testing 2 to 3 years after randomization. Results. PTCA-treated and medically treated patients with double-vessel disease experienced comparable improvement in exercise duration (+1.2 vs. +1.3 min, respectively, p = 0.89), freedom from angin (53% and 36%, respectively, p = 0.09) and improvement of overall quality of life score (+1.3 vs. +4.4, respectively, p = 0.32) at 6 months compared with baseline. This contrasts with greater advantages favoring PTC by these criteri in patients with single-vessel disease (p = 0.0001 to 0.02). Trends present at 6 months persisted at late follow-up. Patients undergoing double-vessel dilation had less complete initial revascularization (45% vs. 83%) and greater average stenosis of worst lesions at 6 months (74% vs. 56%). Likewise, patients with double-vessel disease showed less improved myocardial perfusion imaging (59% vs. 75%). Conclusions. PTC is beneficial in male patients with double-vessel disease; however, we cannot demonstrate the same advantage over medical therapy seen in similar patients with single-vessel disease. Less complete revascularization and greater restenosis for patients having multiple dilations would account for these findings. Alternatively, type 2 error might be operative. Technical advances since completion of this trial might improve these outcomes. These findings warrant further investigation in larger trial.