Cardiac Bypass Surgery and Percutaneous Coronary Intervention (PCI)

• CABG and PCI
  • Coronary Artery Bypass Surgery
  • Percutaneous Coronary Intervention

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• PCI- For Stable Coronary Artery Disease
  • COURAGE- PCI vs Medical Therapy
  • Routine PCI not always cost-effective.
  • From the ASEANZ 2009 meeting

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• PCI- For Unstable Coronary Artery Disease
  • To be added

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• PCI vs CABG for multi-vessel disease
  • To be added

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Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI)

CABG surgery

The randomised trials comparing CABG surgery vs medical therapy were small and are now "old studies". Based on the findings of these randomised trials and other non-randomised data, most would agree with the following.

Mortality is reduced with CABG surgery in those with:

• significant left main stem stenosis
• triple vessel disease with impaired left ventricular systolic function
• triple vessel coronary artery disease with involvement of proximal left anterior descending artery and with normal left ventricular systolic function

Factors associated with greater benefits from CABG surgery:

• severe symptoms
• strongly positive stress test for ischaemia
• severe involvement of proximal segments of large coronary arteries

Mortality reduction has not been convincingly shown in:

• single or double vessel disease with the probable exception of those with severe involvement of the proximal left anterior descending artery, ie before the origin of significant sized septal and diagonal branches.

There is uncertainty about:

• the benefits of CABG surgery just because of presence of silent cardiac ischaemia. A small pilot study (ACIP) suggested patients with silent ischaemia obtain prognostic benefit from revascularisation, but a larger appropriately sized study has not been done to confirm these preliminary findings.

Factors that might translate to greater prognostic benefit with CABG surgery than indicated by older randomised clinical trials:

• improvements in surgical techniques and intensive care that have reduced perioperative morbidity and mortality rates
• greater use of left internal mammary and other arterial grafts that have higher patency rates than vein grafts

Factors that have improved outcome of medically treated patients and thus reduce the advantage of CABG surgery. However, it could be argued that these same benefits should also improve outcomes of those that have had surgery.

• use of low dose aspirin
• use of beta-blockers
• use of statins and other lipid modifying agents
• use of ace-inhibitors