CABG in 2012: Evidence, practice and the evolution of guidelines

Area of Science:

• Cardiovascular Medicine
• Interventional Cardiology
• Clinical Trials

Background:

• Optimal medical therapy is crucial for all coronary artery disease (CAD) patients, regardless of planned interventions.
• Interventions for prognostic reasons require evidence of significant myocardial ischemia (>10% of myocardial mass).

Purpose of the Study:

• To compare the effectiveness of coronary artery bypass grafting (CABG) versus stenting in managing complex coronary artery disease.
• To evaluate survival benefits, repeat revascularization rates, and stroke incidence between CABG and stenting.

Main Methods:

• Analysis of evidence from the SYNTAX trial and its registry component, including 'real-life' patient data.
• Comparison of outcomes for patients with three-vessel CAD and left main stem (LMS) disease.

Main Results:

• CABG demonstrated survival benefits and reduced repeat revascularization compared to stents in 79% of three-vessel CAD and two-thirds of LMS disease patients.
• For less severe CAD, survival was similar between CABG and stents, but CABG had lower repeat revascularization rates.
• SYNTAX showed no difference in stroke for three-vessel disease, but higher stroke incidence with CABG in LMS disease. PRECOMBAT showed no excess mortality or stroke with CABG in low-risk LMS disease patients.

Conclusions:

• CABG remains the treatment of choice for most patients with three-vessel and LMS coronary artery disease due to improved survival and reduced need for repeat procedures.
• Guidelines and multidisciplinary heart teams are essential for guiding intervention decisions in CAD management.