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[Cost-effectiveness analysis of an invasive therapeutic approach to coronary disease]
1Cardiologie, Hôpital cantonal universitaire, Genève.
Insights
Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) improve angina but do not affect mortality in low-risk patients. CABG offers long-term survival benefits, especially for high-risk individuals.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Revascularization strategies, including surgical and percutaneous interventions, are increasingly employed for coronary artery disease.
- Medical management remains a cornerstone, but its efficacy compared to invasive procedures requires ongoing evaluation.
Purpose of the Study:
- To compare the effectiveness and outcomes of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) versus medical treatment.
- To evaluate the impact of these revascularization strategies on angina symptoms, mortality, myocardial infarction, and healthcare costs.
Main Methods:
- Review and synthesis of existing studies comparing surgical revascularization, percutaneous angioplasty (PTCA), and medical management.
- Analysis focused on patient risk stratification, disease extent (single- vs. multivessel), and specific clinical scenarios like acute myocardial infarction.
Main Results:
- Percutaneous angioplasty is more effective than medical treatment for angina symptom control but does not impact mortality or infarction in low-risk populations.
- Coronary artery bypass grafting significantly reduces mortality after 5 years compared to medical treatment, with maximum benefit in high-risk patients.
- In selected patients, PCI and CABG show similar long-term effects on mortality and myocardial infarction. PCI has lower initial costs but higher reintervention rates.
- Direct PTCA in acute myocardial infarction is associated with lower mortality and fewer hemorrhagic events than thrombolysis.
- Invasive strategies can reduce overall healthcare costs due to shorter hospital stays and fewer readmissions.
Conclusions:
- CABG offers significant long-term survival benefits, particularly for high-risk patients, while PCI excels in symptom management for low-risk individuals.
- Both PCI and CABG are viable revascularization options with comparable long-term outcomes in selected patient groups.
- The choice between medical, percutaneous, or surgical revascularization should be individualized based on patient risk, disease characteristics, and cost-effectiveness analysis.
Abstract:
Surgical or percutaneous revascularisation techniques are increasingly used. Percutaneous angioplasty is more efficient than medical treatment for control of angina symptoms, but it does not influence mortality or infarction in a low-risk population. Surgery is associated with a significant decrease in mortality after 5 years, when compared with a strategy of initial medical treatment. Benefit is maximum in high-risk patients. In selected patients with single- or multivessel disease, several studies have demonstrated that surgery and angioplasty have a similar long-term effect on mortality and/or myocardial infarction. The costs of angioplasty are lower than these of surgery, but the percutaneous approach is limited by a more frequent need for reintervention. In acute myocardial infarction, direct PTCA appears to be associated with a lower mortality than thrombolysis, and hemorrhagic events are less frequent. The cost of an invasive strategy is not necessarily higher than that of medical treatment, because the duration of the initial hospital stay and the need for further hospitalizations are reduced.