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Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease
Insights
Percutaneous transluminal coronary angioplasty (PTCA) offers similar five-year survival to coronary-artery bypass grafting (CABG) for multivessel disease. However, CABG showed better survival for diabetic patients, and PTCA required more repeat procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Coronary artery disease (CAD) affects millions globally, necessitating effective revascularization strategies.
- Coronary-artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are primary revascularization methods for CAD.
- Selecting the optimal revascularization strategy for multivessel disease is crucial for long-term patient outcomes.
Purpose of the Study:
- To compare the five-year clinical outcomes of initial percutaneous transluminal coronary angioplasty (PTCA) versus coronary-artery bypass grafting (CABG) in selected patients with multivessel disease.
- To test the hypothesis that an initial PTCA strategy does not lead to poorer outcomes compared to CABG.
- To analyze survival rates, myocardial infarction incidence, and need for repeat revascularization procedures.
Main Methods:
- A randomized trial involving 914 patients assigned to CABG and 915 to PTCA for multivessel disease.
- Patients were followed for an average of 5.4 years, with outcomes analyzed using an intention-to-treat approach.
- Key outcome measures included mortality, Q-wave myocardial infarction, stroke, and subsequent revascularization procedures.
Main Results:
- Five-year survival rates were comparable: 89.3% for CABG vs. 86.3% for PTCA (P=0.19).
- PTCA resulted in significantly lower rates of in-hospital Q-wave myocardial infarction (2.1% vs. 4.6%) and stroke (0.2% vs. 0.8%).
- Subsequent revascularization was needed more frequently after PTCA (54%) compared to CABG (8%). Notably, five-year survival was significantly better with CABG (80.6%) than PTCA (65.5%) in diabetic patients on insulin or oral hypoglycemics.
Conclusions:
- An initial PTCA strategy is a viable alternative to CABG for selected multivessel disease patients, with no significant difference in five-year survival.
- PTCA requires more frequent repeat revascularization procedures compared to CABG.
- For diabetic patients requiring revascularization, CABG demonstrated superior five-year survival compared to PTCA.
Background:
Coronary-artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are alternative methods of revascularization in patients with coronary artery disease. We tested the hypothesis that in selected patients with multivessel disease suitable for treatment with either procedure, an initial strategy of PTCA does not result in a poorer five-year clinical outcome than CABG.
Methods:
Patients with multivessel disease were randomly assigned to an initial treatment strategy of CABG (n = 914) or PTCA (n = 915) and were followed for an average of 5.4 years. Analysis of outcome events was performed according to the intention to treat.
Results:
The respective in-hospital event rates for CABG and PTCA were 1.3 percent and 1.1 percent for mortality, 4.6 percent and 2.1 percent for Q-wave myocardial infarction (P < 0.01), and 0.8 percent and 0.2 percent for stroke. The five-year survival rate was 89.3 percent for those assigned to CABG and 86.3 percent for those assigned to PTCA (P = 0.19; 95 percent confidence interval of the difference in survival, -0.2 percent to 6.0 percent). The respective five-year survival rates free from Q-wave myocardial infarction were 80.4 percent and 78.7 percent. By five years after study entry, 8 percent of the patients assigned to CABG had undergone additional revascularization procedures, as compared with 54 percent of those assigned to PTCA; 69 percent of those assigned to PTCA did not subsequently undergo CABG. Among diabetic patients who were being treated with insulin or oral hypoglycemic agents at base line, a subgroup not specified by the protocol, five-year survival was 80.6 percent for the CABG group as compared with 65.5 percent for the PTCA group (P = 0.003).
Conclusions:
As compared with CABG, an initial strategy of PTCA did not significantly compromise five-year survival in patients with multivessel disease, although subsequent revascularization was required more often with this strategy. For treated diabetics, five-year survival was significantly better after CABG than after PTCA.