[The treatment of stable coronary artery disease: always optimal medical therapy, coronary revascularization only on indication]. / De behandeling van stabiel kransvatlijden.

No trial or meta-analysis in patients with stable coronary artery disease, normal left ventricular function and without left main stenosis, has shown that adding revascularization to optimal medical therapy (OMT) decreases hard endpoints: myocardial infarction (MI) and overall mortality. However, Navarese concludes that OMT with elective revascularization reduces "cardiac" mortality, and is associated with a reduction in spontaneous MI. His meta-analysis is biased by a less hard primary endpoint "cardiac mortality" (often poorly defined and/or not independently assessed), exclusion of revascularisation-related MI and inclusion of vintage trials without platelet aggregation inhibitors, statins or PCIs. Overall the description of OMT is incomplete; even after 2000 the LDL cholesterol values are missing in half of the trials. Trials and meta-analyses without a clear focus on OMT and without clear and hard primary endpoints do not provide clear information for the doctor in the consulting room who wants to make the best treatment choice.

[Stable angina pectoris deserves better treatment]. / Behandeling van stabiele angina pectoris moet beter.

In the Netherlands, the burden of coronary artery disease is higher than that of any other disease. The healthcare costs amount to approximately 2.3 billion per year. Cardiovascular risk management (CVRM) reduces mortality and prevents myocardial infarction in patients with stable angina pectoris (AP). In patients with stable AP without a left main coronary artery stenosis or heart failure, percutaneous coronary intervention (PCI) does not reduce mortality, nor does it prevent myocardial infarction. The effect on AP is questionable. Improvement of treatment of stable AP can be achieved using intensive CVRM and targeted anti-anginal medication and only if optimal medical therapy (OMT) is not sufficient, a PCI. Clear communication and sharing of tasks between general practitioners and cardiologists in the form of network medicine is necessary, making use of multidisciplinary guidelines and unambiguous, jointly applied quality indicators. Financing of the treatment trajectory for stable AP should promote this integral approach.