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Factors affecting the therapeutic choice in patients with multivessel coronary artery disease. The Studio Lombardo
S De Servi1, S Galli, M Onofri
1Division of Cardiology, Policlinico San Matteo, Pavia, Italy.
Insights
Coronary bypass grafting is the primary treatment for multivessel coronary artery disease, but percutaneous coronary angioplasty (PTCA) is chosen in specific cases. Advancements in PTCA technology are needed to favor less invasive procedures.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Multivessel coronary artery disease (CAD) requires careful treatment decisions between revascularization strategies.
- Clinical and angiographic factors significantly influence the choice between percutaneous coronary angioplasty (PTCA) and coronary bypass grafting (CABG).
Purpose of the Study:
- To determine the relationship between clinical and angiographic findings and the selection of PTCA versus CABG in patients with multivessel CAD.
- To identify predictors for revascularization versus medical treatment, and for CABG versus PTCA in treated patients.
Main Methods:
- A prospective survey involving 1468 patients with multivessel CAD undergoing coronary arteriography across 14 Italian centers.
- Multivariate logistic regression analysis was employed to identify significant clinical and angiographic predictors.
- Analysis focused on factors influencing the choice between revascularization and medical management, and between CABG and PTCA.
Main Results:
- Coronary bypass grafting was performed in 53% of patients, PTCA in 28%, and medical treatment in 19%.
- Revascularization decisions were influenced by unstable angina, left anterior descending artery disease, ejection fraction, and prior bypass surgery history.
- CABG was favored for left anterior descending artery disease, three-vessel disease, and occluded vessels, while PTCA was associated with prior interventions, non-Q wave MI, and stent possibility.
Conclusions:
- Coronary bypass grafting remains the predominant treatment for multivessel CAD, reflecting current clinical practice.
- The study provides a benchmark for future comparisons as interventional cardiology advances.
- Further technological improvements in PTCA are necessary to promote its adoption over surgical procedures.
Objective:
To assess how clinical and angiographic findings are related to the decision to carry out coronary angioplasty (PTCA) or coronary bypass grafting in patients with multivessel coronary artery disease.
Design:
Prospective survey carried out in 14 centres in the Lombardia region of Italy.
Patients:
1468 consecutive patients under going coronary arteriography for known or suspected ischaemic heart disease between May and October 1994, who were found to have multivessel coronary artery disease.
Main Outcome Measures:
Multivariate analysis was undertaken using stepwise logistic regression to identify the clinical and angiographic variables correlated with revascularisation (v medical treatment) in all of patients, and with surgery (v angioplasty) in the subset of revascularised patients.
Results:
In all patients the clinical decision after coronary arteriography was made by physicians of each participating centre on the basis of their experience and clinical judgment: 53% of patients had bypass surgery, 28% had PTCA, and 19% continued medical treatment. The choice of a revascularisation procedure was directly related to a clinical diagnosis of unstable angina (P < < 0.001), the presence of left anterior descending artery disease (P < < 0.001), and to an ejection fraction > or = 40% (P < < 0.001), and inversely related to history of previous coronary bypass surgery (P < < 0.001). In revascularised patients, bypass surgery was the preferred treatment in patients with left anterior descending artery disease (P < < 0.001), three-vessel disease (P < < 0.001), and in those with at least one occluded vessel (P = 0.008). The choice of PTCA was significantly related to history of previous PTCA (P < < 0.001) or coronary bypass surgery (P < < 0.001), to a clinical diagnosis of non-Q wave myocardial infarction (P = 0.002), and to the possibility of implanting an intracoronary stent (P = 0.01).
Conclusions:
Bypass surgery is still the most widely used treatment for patients with multivessel coronary artery disease. This analysis provides a basis for comparison with future developments in the treatment of such patients. Further advancements in PTCA technology are needed to tilt the balance in favour of this less invasive procedure.