Contents
Outcomes
Percutaneous Coronary Intervention vs. Medical Therapy
Percutaneous coronary intervention is more effective than medical therapy in relieving angina, but it confers no greater survival benefit. Aggressive lipid-lowering therapy appears to be as effective as percutaneous coronary intervention plus usual medical care for preventing ischemic events.
Coronary Artery Bypass Grafting vs. Medical Therapy
CABG produces better survival rates than does medical therapy, in selected circumstances, and is recommended for symptomatic patients with left main coronary artery disease, 3-vessel CAD, or 2-vessel CAD marked by stenosis of the proximal left anterior descending artery. Coronary artery bypass graft surgery is more effective than medical therapy for the relief of angina, although this benefit narrows after a period of 5 to 10 years, most likely due to advancing native vessel CAD coupled with vein-graft attrition.
Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting
Outcomes following percutaneous coronary intervention and CABG have been compared in high-risk patients. The 2 largest studies in the U.S. were the Emory Angioplasty versus Surgery Trial (EAST) and the Bypass Angioplasty Revascularization Investigation (BARI). In both trials, percutaneous coronary intervention was limited solely to angioplasty. Similarly, current CABG techniques, including the more frequent use of arterial conduits, were not included in either trial. EAST results have demonstrated that the long-term survival rates following percutaneous coronary intervention and CABG are comparable. BARI results have indicated that CABG produces better long-term survival rates than PCI (pre-stent). However, the benefit of CABG in BARI was not apparent until 7 years postoperatively, and it was largely attributable to the significantly higher survival rate in the subgroup of patients with diabetes mellitus. Both trials have shown that CABG is superior to PCI in relieving angina and obviating the need for repeat revascularization procedures. With the introduction of drug-eluting stents, coupled with improved catheterization techniques, CAD treatment is shifting away from bypass surgery toward a percutaneous approach. Restenosis rates have been lowered significantly and acute thrombotic complications are rare given the advances in antiplatelet therapy.
