Multivessel coronary artery disease: quantifying how recent trials should influence clinical practice

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Multivessel disease (MVD) accounts for the majority of coronary revascularizations.
• Treatment options for MVD include medical therapy, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG).
• CABG improves survival compared to medical therapy and is equivalent to PCI in low-complexity MVD.

Purpose of the Study:

• To compare the effectiveness of CABG versus PCI in patients with multivessel disease.
• To evaluate long-term outcomes, including mortality, myocardial infarction, and repeat revascularization.
• To discuss the integration of clinical trial evidence, comparative effectiveness studies, and economic factors in treatment decisions.

Main Methods:

• Review of clinical trial data and comparative effectiveness studies.
• Analysis of outcomes in patients with complex MVD, including diabetic patients.
• Consideration of inappropriateness criteria, decision aids, and economic impact.

Main Results:

• CABG demonstrates improved long-term survival, reduced myocardial infarction, and lower repeat revascularization rates compared to PCI in complex MVD.
• These benefits are more significant in diabetic patients and those with anatomically complex lesions.
• While CABG has higher upfront costs, it is economically favorable in the long term.

Conclusions:

• CABG is the preferred revascularization strategy for complex MVD, particularly in diabetic patients, due to superior long-term outcomes.
• Evidence-based practice integration through tools like inappropriateness criteria and decision aids is crucial for optimal patient care.
• Economic considerations support CABG as a cost-effective long-term solution for managing MVD despite higher initial investment.