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Do differences in repeat revascularization explain the antianginal benefits of bypass surgery versus percutaneous
Suzanne V Arnold1, Elizabeth A Magnuson, Kaijun Wang
1St. Luke's Mid America Heart Institute, Kansas City, MO 64111, USA.
Insights
Coronary artery bypass grafting (CABG) offers greater angina relief than percutaneous coronary intervention (PCI) for multivessel coronary disease. Repeat revascularization did not fully explain this benefit, suggesting CABG
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Multivessel coronary artery disease (CAD) patients undergoing CABG report less angina than those treated with PCI.
- The mechanism for greater angina relief with CABG and the role of repeat revascularization in PCI patients remain unclear.
Purpose of the Study:
- To investigate the mechanism of superior angina relief with CABG compared to PCI.
- To determine if repeat revascularization in PCI patients accounts for the observed differences in angina relief.
Main Methods:
- The Synergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) trial randomized 1800 patients with 3-vessel or left main CAD to CABG or PCI.
- Health status was assessed using the Seattle Angina Questionnaire and MOS SF-36 at baseline and 12 months.
- Longitudinal models assessed the association between repeat revascularization and health status.
Main Results:
- Patients requiring repeat revascularization reported worse angina frequency in both groups.
- PCI patients needing repeat procedures had significantly worse angina scores (8.5-19.8 points) than those not needing them.
- Among patients not requiring repeat revascularization, CABG and PCI showed similar effects on angina frequency.
Conclusions:
- Repeat revascularization does not fully explain the antianginal benefit of CABG in multivessel CAD.
- The impact of repeat revascularization on angina differs between CABG and PCI, limiting its role in direct treatment comparisons.
Background:
Patients with multivessel coronary disease treated with coronary artery bypass graft (CABG) have less angina than those treated with percutaneous coronary intervention (PCI); however, there is uncertainty as to the mechanism of greater angina relief with CABG and whether more frequent repeat revascularization in patients treated with PCI could account for this treatment difference.
Methods And Results:
In the Synergy between percutaneous coronary intervention (PCI) with TAXUS and Cardiac Surgery trial, 1800 patients with 3-vessel or left main coronary artery disease were randomized to CABG or PCI with paclitaxel-eluting stents. Health status was assessed at baseline, 1, 6, and 12 months, using the Seattle Angina Questionnaire and the Medical Outcomes Study Short Form General Health Survey, and the association between repeat revascularization and health status during follow-up was assessed using longitudinal models. In adjusted analyses, patients who underwent repeat revascularization had worse angina frequency scores than patients who did not in both treatment groups, with differences of 8.5 points at 6 months and 3.1 points at 12 months in patients treated with PCI and 19.8 points at 6 months and 11.2 points at 12 months in patients with patients treated with CABG. Among patients who did not require repeat revascularization, the adjusted effect of CABG versus PCI on 12-month angina frequency scores was nearly identical to the overall benefit in the intention-to-treat analysis.
Conclusions:
Among patients with multivessel coronary artery disease treated with PCI or CABG, the occurrence of repeat revascularization during follow-up did not fully explain the antianginal benefit of CABG in the overall population. The differential association between repeat revascularization and anginal status, according to the type of initial revascularization procedure, suggests that this end point should play a limited role in any direct comparison of the 2 treatment strategies.
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