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An estimated 4.1% of the Western population develops stable angina pectoris (SAP) during life,1 which is currently treated by optimal medical therapy, often followed by revascularization, performed percutaneously [i.e. percutaneous coronary intervention (PCI)] or surgically [i.e. coronary artery bypass grafting (CABG)]. However, recent studies found no superiority of revascularization in SAP patients without left-main stenosis on 1- and 2-year prognoses compared to optimal medical therapy.2,3 A potential alternative, cardiac rehabilitation (CR), demonstrated fewer symptoms4 and adverse advents5 in previous small randomized controlled trials, whilst a recent cohort study showed lower 18-month mortality, rehospitalization, and cardiovascular morbidity compared to PCI.6 More research is required to gain insight into clinical outcomes of CR, but also whether CR represents a cost-effective alternative to revascularization given the lower costs of CR7,8 and large proportion of patients with SAP undergoing PCI.9,10 Therefore, we compared the effects of CR vs. PCI on major adverse cardiovascular events (MACE), new revascularizations, chest pain, and associated healthcare costs over a period of 24 months in patients with SAP.

Background: Currently, in the majority of patients with stable angina pectoris (SAP) treatment consists of optimal medical treatment, potentially followed by coronary angiography and subsequent coronary revascularisation if necessary”. Recent work questioned the effectiveness of these invasive procedures in reducing re-events and improving prognosis. The potential of exercise-based cardiac rehabilitation on clinical outcomes in patients with coronary artery disease is well-known. However, in the modern era, no studies compared the effects of cardiac rehabilitation versus coronary revascularisation in patients with SAP. Methods: In this multicentre randomised controlled trial, 216 patients with stable angina pectoris and residual anginal complaints under optimal medical treatment will be randomised to: 1) usual care (i.e., coronary revascularisation), or 2) a 12-month cardiac rehabilitation (CR) programme. CR consists of a multidisciplinary intervention, including education, exercise training, lifestyle coaching and a dietary intervention with a stepped decline in supervision. The primary outcome will be anginal complaints (Seattle Angina Questionnaire-7) following the 12-month intervention. Secondary outcomes include cost-effectiveness, ischemic threshold during exercise, cardiovascular events, exercise capacity, quality of life and psychosocial wellbeing. Discussion: In this study, we will examine the hypothesis that multidisciplinary CR is at least equally effective in reducing anginal complaints as the contemporary invasive approach at 12-months follow-up for patients with SAP. If proven successful, this study will have significant impact on the treatment of patients with SAP as multidisciplinary CR is a less invasive and potentially less costly and better sustainable treatment than coronary revascularisations. Trial registration: Netherlands Trial Register, NL9537. Registered 14 June 2021.