Invasive Strategy Offers No Added Benefit in Low-Risk SCAD Patients and Raises Bleeding Risk: Study Finds

In patients with SCAD, percutaneous coronary intervention (PCI) did not significantly reduce ischemic events compared to conservative management and was associated with an increased risk of bleeding (hazard ratio 1.59), the researchers reported in BMC Medicine. However, among those classified as moderate-to-high risk, PCI was linked to a 33% reduction in ischemic events and a 27% decrease in all-cause mortality without an accompanying rise in bleeding risk. These findings suggest that risk stratification could be crucial in guiding optimal treatment strategies for SCAD.

The long-term benefits of percutaneous coronary intervention in patients with stable coronary artery disease, as compared to conservative management, have remained a topic of ongoing debate. To address this uncertainty, Zizhao Qi, Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China, and colleagues aimed to assess the impact of an initial invasive strategy versus a conservative approach on long-term clinical outcomes in SCAD patients, using risk stratification to identify which subgroups may benefit most from each treatment pathway.

For this purpose, the researchers conducted a sub-analysis of the multicenter, observational OPT-CAD (Optimal antiPlatelet Therapy for Chinese patients with Coronary Artery Disease) study. They compared clinical outcomes in SCAD patients who were initially managed with either PCI (invasive strategy) or conservative treatment, based on their risk levels determined by the OPT-CAD score.

The primary outcome was the occurrence of ischemic events over five years, including cardiac death, myocardial infarction, and ischemic stroke. Secondary outcomes included all-cause mortality and major bleeding events, defined as BARC types 2, 3, or 5.

The study led to the following findings:

• The study included 1767 patients (58.0%) in the conservative group and 1278 patients (42.0%) in the invasive group.
• Overall, the invasive strategy did not lower the risk of ischemic events compared to the conservative approach.
• However, it was linked to a higher risk of BARC type 2, 3, or 5 bleeding (adjusted HR 1.59).
• In the low-risk subset (N = 2030), outcomes were similar, with no added benefit from the invasive strategy.
• In the moderate-to-high-risk subset (N = 1015), the invasive approach significantly reduced the risk of ischemic events (HR 0.67).
• A trend toward reduced all-cause mortality was also observed in this group (HR 0.73).
• No increased risk of bleeding was noted in moderate-to-high-risk patients receiving invasive treatment.

“In patients with stable coronary artery disease, an initial invasive strategy did not provide additional clinical benefit over conservative management and was associated with a higher risk of bleeding,” the researchers noted. “However, among those classified as moderate-to-high risk based on the OPT-CAD score, the invasive approach was linked to a reduction in ischemic events without an increased risk of bleeding”

“These findings underscore the potential utility of the OPT-CAD score in guiding personalized treatment decisions for patients with SCAD,” they concluded.

Reference:

Qi, Z., Qiu, M., Xu, Y. et al. Comparative outcomes of invasive versus conservative strategy in stable coronary artery disease patients: a risk-stratification-based hypothesis-generative study. BMC Med 23, 199 (2025). https://doi.org/10.1186/s12916-025-04020-2