To stent or not to stent?

Now onto today's mini JC topic Stents vs medical therapy ALONE for stable coronary artery disease

Stable coronary artery disease (or those without EKG signs of ischemia or positive troponin) are often admitted to the hospital, especially if they carry multiple risk factors. Most of us never followup on these or check in care connection the next day to see what happens to our stable chest pain patients. Usually we thought they probably couldn't go home OR  we had hoped that if they had some large coronary artery lesion that needed stenting we would have saved a future MI or maybe a fatality. 
A meta-analysis was recently completed comparing MAXIMAL medical therapy to percutaneous coronary intervention in patients with STABLE coronary artery disease. This study was modern that only RCT who included patients who got modern maximal medical therapy (beta blockers, ACEI, anti-plt regimens) compared to stenting (no angioplasty alone). 
Heres what was found:
1. Why is this topic important?
We admit lots of chest pain patients to the hospital with vague stories with negative troponins and non-ischemic EKG's, which increased LOS, and hospital resource utilization, the question remains where is the benefit?
2. What does the study attempt to show?
This is a meta-analysis of RCT comparing maximal medical therapy to stent placement in patients with stable coronary artery disease, in the modern medical era (ACEI, BB, new fancy anti-plt agents). Outcomes included: Death, MI, or non-planned revascularization and persistent angina
3. What were the key findings?
8 trials for a total of 7229 patients were found.
Death rate for stent implantation vs medical therapy was 8.9 vs 9.1% perspectively (OR 0.98 95% CI 0.84-1.16)
NON-fatal MI for stent 8.9% and medical therapy 8.1% (OR 1.12 95% CI 0.93-1.34)
UN-planned revascularization for stent vs medical 21.4% vs 30.7% (OR 0.78 95% 0.57-1.06)
Persistent angina 29% and 33% (OR 0.8 95% CI 0.6-1.05) 
4. How is patient care impacted?
Patients with stable coronary artery disease should be placed on maximal medical therapy and seen in their doctors office not admitted to the hospital where incentives to have invasive procedures persist. The fact that no benefit is seen in mortality or recurrent MI, AND many of these studies did not use troponin measurements (still using CK-MB's) means that the Nonfatal MI was probably higher in the stent group than actually demonstrated, this is because stenting has a periprocedural MI rate between 5-30% due to distal embolization of plaques, or distal side occlusions and was not detected on the less sensitive CK-MB assays. 
5. IS this an area of controversy?
Yes, cardiologists have a strong incentive to cath patients who likely have disease (09% stenosis, 70% stenosis etc) and place stents, they think and we think this is helping patients live longer and symptom free. But in reality its a costly intervention and we have incomplete evidence of the pathophysiology of plaque rupture. therefore what we end up with is an inability to reject the null hypothesis, PCI in patients with stable CAD does not result in a mortality reduction when compared to maximal medical therapy alone. 
6. Major limitations of the study
This is a meta-analysis of randomized controlled trials, and they tried to select out patients who got MAXIMAL medical therapy and stents + MAXIMAL medical therapy. They had almost 7500 patients, but did not show a statistical or clinically significant benefit to stents over medical therapy for stable CAD. This nebulous outcome of unplanned revascularizations tended to be less frequent in the patients who got stented previously, but I think this is more INHERENT in the fact that they already had PCI and this made a cardiologist less inclined to interrogate the patients coronaries AGAIN. 
Initial Coronary Stent Implantation With Maximal Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease
Stergioplous et al