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Percutaneous coronary intervention in the 1990s. Results in patients with single or multivessel disease
1Cleveland Clinic Foundation, Department of Cardiology, OH.
Insights
Percutaneous coronary intervention (PCI) is evolving, with ongoing studies comparing it to bypass surgery. PCI remains primary for single-vessel disease, while bypass surgery is preferred for diffuse disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- The role of percutaneous coronary intervention (PCI) compared to other therapies is dynamic.
- Randomized trials are crucial for defining the optimal use of angioplasty and bypass surgery.
Purpose of the Study:
- To evaluate the evolving role of percutaneous revascularization versus bypass surgery in coronary artery disease treatment.
- To identify patient subgroups where each revascularization strategy is most appropriate.
Main Methods:
- Review of ongoing randomized comparative studies.
- Analysis of procedural outcomes and patient heterogeneity in treatment effectiveness.
Main Results:
- Percutaneous revascularization is likely the primary therapy for single-vessel disease with limiting angina or significant ischemia.
- Bypass surgery may be superior for ostial/proximal left anterior descending lesions and diffuse multivessel disease.
- PCI is preferred for focal multivessel disease; bypass surgery for diffuse disease and impaired left ventricular function.
Conclusions:
- PCI is expected to expand its domain in treating coronary artery disease due to procedural improvements.
- Careful consideration of patient-specific factors and disease complexity is essential for selecting revascularization strategy.
Abstract:
The proper role of percutaneous coronary intervention in the 1990s relative to other forms of therapy remains to be defined and appears to be a continually moving target. Ongoing randomized comparative studies with bypass surgery in patients with complex disease will assist in defining the role of angioplasty and bypass surgery, but should be viewed carefully with regard to the apparent improvements in procedural outcome and demonstrated effective patient heterogeneity on outcome. It is likely that percutaneous revascularization will remain the mainstay of therapy for patients with single vessel coronary disease who have lifestyle limiting angina or can be demonstrated to have large areas of ischemia with little provocation. One exception to this generalization might be for patients with ostial or very proximal left anterior descending narrowings in whom bypass surgery might be a better long-term therapy. Unfortunately, little truly comparable data exists for patients treated with percutaneous revascularization and bypass surgery within this group. Percutaneous revascularization will also probably remain the preferred therapy for patients with relatively focal multivessel coronary disease whilst bypass surgery will remain the preferred approach for patients with more diffuse disease and possibly for those with moderate or moderate to severe left ventricular contractile impairment. It might be expected, however, that improvements in procedural outcome with percutaneous revascularization will allow interventionalists to gradually encroach upon the previous domain of cardiac surgeons.