Coronary Bypass Surgery versus Percutaneous Coronary Intervention

The Saga Continues

Gustavo Goldenberg; Ran Kornowski

Disclosures

Interv Cardiol. 2012;4(6):653-660. 

In This Article

Abstract and Introduction

Abstract

Coronary artery bypass graft surgery and percutaneous coronary intervention are the treatment options in patients with ischemia and multivessel coronary artery disease (CAD). Comparisons of coronary artery bypass graft and percutaneous coronary intervention have provided conflicting information. For years, experts have debated over the optimal treatment for patients with multivessel CAD. Current data indicate that clinical outcomes following invasive revascularization depend on patient characteristics, cardiac function, coronary disease distribution, and/or the number of diseased vessels. Lately, new data on treatment paradigms have enabled tailoring of treatment to fit the patient, with the anatomic SYNTAX score and some additional variables. This new data should be scrutinized to ensure its successful clinical utilization to provide individualized care for patients with CAD. In this article, we address some important coronary revascularization issues. We present and analyze the new information in the context of its clinical relevance, contemporary revascularization measures, and other tools designed to improve the care of patients with multivessel CAD.

Introduction

The debate over the optimal method of revascularization for patients with coronary multivessel disease (MVD) has raged on for many years, and it continues to date. In fact, the recent report of the Comparative Effectiveness of Revascularization Strategies Trial (ASCERT) has rekindled the professional debate.[1] This large sample report was one of the most comprehensive data sets published that described coronary revascularization outcomes in patients aged 65 years or older. Although no difference in mortality was evident between the methods after 1 year, the adjusted all-cause mortality after 4 years was lower with coronary artery bypass grafting (CABG) surgery than with percutaneous coronary intervention (PCI). The ASCERT data set showed a long term prognostic advantage of CABG over PCI that was independent of different subgroups. This advantage was also evident among patients that had propensity scores consistent with the selection of PCI as the preferred therapeutic strategy. However, the ASCERT trial did not provide information about the coronary anatomy of treated patients. This information is crucial to the therapeutic decision-making process.

As might be expected from a nonrandomized study, the two treatment groups differed significantly. The propensity scores were also divergent, showing a potential for selection bias. However, other observational studies showed results similar to those presented in ASCERT.[2,3] The large number of patients and the consistency of the results with previous reports lent 'weight' to the trial results that favored the CABG revascularization strategy. The New York Registry[2] and a meta-analysis by Hlatky[3] also demonstrated results in favor of CABG. It is notable that in those studies, the survival benefit of surgery also increased over time. In the New York Registry,[2] the CABG arm had more patients with triple-vessel disease and/or multiple comorbidities than in the PCI arm. This fact reinforces the potential advantage of CABG over mutivessel PCI. The meta-analysis by Hlatky[3] showed that in patients with diabetes, mortality was substantially lower in the CABG group than following PCI. Nonetheless, in patients without diabetes, the mortality was comparable. Moreover, in patients younger than 65 years of age, no difference in long-term mortality was observed between CABG and PCI. Treatment effect was not altered by the number of diseased vessels or other baseline characteristics.

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