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Abstract 27: Long Term Outcomes with Optimal Medical Therapy in Patients Seeking a Second Opinion Regarding Invasive Coronary Angiography

Whether invasive coronary angiography (ICA) data is required to properly select patients (pts) for optimal medical therapy (OMT) is still a matter of debate. As part of a larger prospective cohort study of OMT, we examined rates of myocardial infarction (MI) and revascularization rates (revasc) in 63 pts with stable coronary artery disease (CAD) who had sought a second opinion (SO) regarding ICA in the period from 1992 to 1998. Management decisions were based primarily on history, physical examinations, and non-invasive data. During the follow-up period, decisions to pursue an invasive evaluation or revasc were based on stability of symptoms, LV function, and exercise duration. Revasc was defined as any percutaneous intervention or coronary artery bypass graft (CABG). MI was defined as meeting two of the three WHO criteria or a typical pattern of MI on a myocardial perfusion study or 2-D Echocardiography. Revasc and MI were ascertained up to June 2005. Survival status was ascertained as of December 2008.
 
 Results:
 We agreed with the first opinion for ICA in only 7 pts (11%), but in 56 pts (89%) we recommended deferring ICA, and this was accepted by 54 pts. These pts were then managed with OMT. Compared to the larger cohort of CAD pts, SO pts were younger (mean age 62.5 yrs), less likely to have a prior MI, and more likely to be on beta-blockers and lipid lowering agents at entry. 30.2% of SO pts had no angina, 31.7% had CCS class 1 angina, and 38.1% had CCS class 2 angina pectoris. No pts had CCS class 3 or 4 angina. The mean LVEF was 62.3%. Mean exercise treadmill duration was 7.4 minutes.
 
 In the entire group of 63 pts, the annualized mortality rate was 1.7% over an average follow up period of 12.98 years. A total of 31 revasc events and 10 non-fatal MIs occurred over a follow up period of 7.12 years. The overall incidence of revasc was 6.9% annually, and of non-fatal MI 2.2%. In the subgroup of pts who did not have ICA the incidence rate of non-fatal MI was 2.6% and the incidence rate of revasc was 6.1%. Of the 9 pts who proceeded to ICA, 8 were revascularized, half within 6 weeks. There were no MIs post revasc in the follow up period in this group.
 
 Conclusions:
 Long-term revasc and MI rates were low in pts with stable CAD who were advised to pursue ICA but deferred the procedure after a SO, and were comparable to rates in recent randomized clinical trials such as COURAGE and BARI2D; annualized mortality rates were similarly low. Second opinion recommendations for ICA were well-accepted in pts who sought them, and reduced the number of revasc procedures that would otherwise have occurred. Our results suggest that ICA is not a pre-requisite in pursuing OMT in pts with acceptable non-invasive profiles.
