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Percutaneus Coronary Disease vs Coronary Artery Bypass Grafting in Severe Coronary Artery Disease
Background
Cardiovascular disease (CVD) has risen world consent about it. Since cardiovascular disease is the leading cause of death worldwide. According to WHO data, it's estimated about 17.5 millions people die from CVD annually.
Coronary artery disese causing severe morbidity and poor quality of life since limitation of activities, pain, long-term care. There are many modalities in treatment for coronary artery disease, such as PCI and CABG. Both of them aims at improving coronary blood flow and prevention of recurrent heart attack.
Coronary-artery bypass grafting has became the standard of care for symptomatic patients with coronary artery disease since its introduction in 1968. Recent advances and innovation in coronary surgery e.g., off-pump CABG, smaller incisions, enhanced myocardial preservation, use of arterial conduits, and improved postoperative care have reduced morbidity, mortality, and rates of graft occlusion.
Percutaneous coronary intervention (PCI) was introduced in 1977. This approach has been developed in technology, has made it possible to treat increasingly complex lesions and patients with a history of clinically significant cardiac disease, risk factors for coronary artery disease, coexisting conditions, or anatomical risk factors.
Several trials has been done to compare efficacy of bare-stents PCI with CABG in patients with multivessel disease. The results showed similar survival rates but higher re-intervention rates among patients with bare-metal stents at 5 years duration. Some researchs have shown a significant long-term survival advantage with surgical approach.
New technique PCI, with drug-eluting, using anti cell-proliferation agents such as Taxus, has been developed. Randomized trials comparing drug-eluting stents with bare-metal stents have shown significant reductions in the
rate of repeat intervention, with similar rates of death and myocardial infarction. These data is used as a base line for expanding PCI usage in patients with complex coronary anatomical features, though most randomized trials such patients.
According to current guidelines, CABG remains the treatment of choice for patients with severe coronary artery disease, including those with left main coronary artery disease and those with three-vessel disease.
Since, widely used of PCI in severe case of Coronary artery disease with lack of evidence. There is needed to do systematic comparison between PCI and CABG. The results of the trials perhaps can be used as basic for choosing proper treatment for the patients. Or The Right Treatment for The Right Patients
Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, researchers assessed the optimal revascularization strategy for patients with
previously untreated three-vessel or left main coronary artery disease and defined the populations of patients for whom only one revascularization
method will be effective.
Summary of trials
The SYNTAX trial was designed as a noninferiority trial with the primary endpoint of death, stroke myocardial infarction (MI), or repeat evascularization at 12 months. The study planned to evaluate the outcome of the subgroup of patients with three-vessel or left main separately if the overall trial demonstrated noninferiority.
The study showed that PCI is associated with higher re-intervention procedures rates compare with CABG group. However, the rates of death and heart attack were not different between two group. While stroke is higher in CABG group compare with PCI.
Although this is not an expected result, further analysis showed that the extent of disease was an important factor, as those with the most complex coronary disease did better with CABG, while those with an intermediate or low scores showed similar outcomes between the groups.
Take Home Message
With the recent 5 year follow up study after procedures, the result showed that LM Stenting is still showing equivalent in mortality, the results may shift balance more toward to PCI. But, CABG is associated with lower re-intervention procedures compare with PCI..
By the way, in subgroup analysis PCI-with drug-eluting showed significant efficacy in patient with Left-Main Artery disease or same outcome with CABG. There will be endless debate on this issue, but PCI will be preferred and most utilized therapy for unprotected left-main lesions in the future. Meanwhile, the treatment decisions should be individualized and clinically relevant, with careful informed consent before making a choice.
The higher stroke rate in CABG is also an important concern for patients undergoing CABG and should impact patient selection. Importantly, the two groups showed no difference in death, cardiac death, or MI. But the SYNTAX has limitation due to its only 1 year follow up, compare the others research such MAIN-COMPARE trial about 5 year follow up.
But, from this data, we can keep in our mind that patient selection and the extent of the disease, patient preference, complications of the procedures are important factor in determining treatment choice.
Cardiovascular disease (CVD) has risen world consent about it. Since cardiovascular disease is the leading cause of death worldwide. According to WHO data, it's estimated about 17.5 millions people die from CVD annually.
Coronary artery disese causing severe morbidity and poor quality of life since limitation of activities, pain, long-term care. There are many modalities in treatment for coronary artery disease, such as PCI and CABG. Both of them aims at improving coronary blood flow and prevention of recurrent heart attack.
Coronary-artery bypass grafting has became the standard of care for symptomatic patients with coronary artery disease since its introduction in 1968. Recent advances and innovation in coronary surgery e.g., off-pump CABG, smaller incisions, enhanced myocardial preservation, use of arterial conduits, and improved postoperative care have reduced morbidity, mortality, and rates of graft occlusion.
Percutaneous coronary intervention (PCI) was introduced in 1977. This approach has been developed in technology, has made it possible to treat increasingly complex lesions and patients with a history of clinically significant cardiac disease, risk factors for coronary artery disease, coexisting conditions, or anatomical risk factors.
adopted from http://seniorjournal.com/NEWS/Health/2007/7-10-04-Angioplasty.htm
New technique PCI, with drug-eluting, using anti cell-proliferation agents such as Taxus, has been developed. Randomized trials comparing drug-eluting stents with bare-metal stents have shown significant reductions in the
rate of repeat intervention, with similar rates of death and myocardial infarction. These data is used as a base line for expanding PCI usage in patients with complex coronary anatomical features, though most randomized trials such patients.
According to current guidelines, CABG remains the treatment of choice for patients with severe coronary artery disease, including those with left main coronary artery disease and those with three-vessel disease.
Since, widely used of PCI in severe case of Coronary artery disease with lack of evidence. There is needed to do systematic comparison between PCI and CABG. The results of the trials perhaps can be used as basic for choosing proper treatment for the patients. Or The Right Treatment for The Right Patients
Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, researchers assessed the optimal revascularization strategy for patients with
previously untreated three-vessel or left main coronary artery disease and defined the populations of patients for whom only one revascularization
method will be effective.
adopted from http://www.cumc.columbia.edu/dept/cs/pat/cardiac/cabg.html
Summary of trials
The SYNTAX trial was designed as a noninferiority trial with the primary endpoint of death, stroke myocardial infarction (MI), or repeat evascularization at 12 months. The study planned to evaluate the outcome of the subgroup of patients with three-vessel or left main separately if the overall trial demonstrated noninferiority.
The study showed that PCI is associated with higher re-intervention procedures rates compare with CABG group. However, the rates of death and heart attack were not different between two group. While stroke is higher in CABG group compare with PCI.
Although this is not an expected result, further analysis showed that the extent of disease was an important factor, as those with the most complex coronary disease did better with CABG, while those with an intermediate or low scores showed similar outcomes between the groups.
Take Home Message
With the recent 5 year follow up study after procedures, the result showed that LM Stenting is still showing equivalent in mortality, the results may shift balance more toward to PCI. But, CABG is associated with lower re-intervention procedures compare with PCI..
By the way, in subgroup analysis PCI-with drug-eluting showed significant efficacy in patient with Left-Main Artery disease or same outcome with CABG. There will be endless debate on this issue, but PCI will be preferred and most utilized therapy for unprotected left-main lesions in the future. Meanwhile, the treatment decisions should be individualized and clinically relevant, with careful informed consent before making a choice.
adopted from http://evolution.berkeley.edu
The higher stroke rate in CABG is also an important concern for patients undergoing CABG and should impact patient selection. Importantly, the two groups showed no difference in death, cardiac death, or MI. But the SYNTAX has limitation due to its only 1 year follow up, compare the others research such MAIN-COMPARE trial about 5 year follow up.
But, from this data, we can keep in our mind that patient selection and the extent of the disease, patient preference, complications of the procedures are important factor in determining treatment choice.
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