Coronary angioplasty versus coronary artery surgery

Results from the Randomized Intervention Treatment of Angina Trial (RITA-1):

• CABG involved a longer initial hospitalization and convalescence than PTCA
• emergency CABG required in 4% of PTCA group
• risk of myocardial infarction similar during treatment and follow-up periods in non-diabetics
• CABG reduces long-term mortality in diabetic patients
• risk of a major cardiac event (e.g. death, MI, additional revascularization procedure) greater in PTCA group
• both procedures were effective for symptom relief; CABG was slightly more effective at 2 years
• greater need for anti-anginal medication in PTCA patients
  
  
• a collaborative analysis comparing the two treatments concluded that (2):
  • long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes
  • CABG might be a better option for patients with diabetes and patients aged 65 years or older - mortality was found to be lower in these subgroups
• in severe coronary artery disease:
  • CABG remains the standard of care for patients with three-vessel or left main coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year (3)

NICE state with respect to stable angina (4):

• people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment
• consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment
  • offer coronary angiography to guide treatment strategy for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. Additional non-invasive or invasive functional testing may be required to evaluate angiographic findings and guide treatment decisions
    
    
  • offer CABG to people with stable angina and suitable coronary anatomy when:
    • their symptoms are not satisfactorily controlled with optimal medical treatment and
    • revascularisation is considered appropriate and
    • PCI is not appropriate
      
      
  • offer PCI to people with stable angina and suitable coronary anatomy when:
    • their symptoms are not satisfactorily controlled with optimal medical treatment and
    • revascularisation is considered appropriate and
    • CABG is not appropriate
      
      
  • when either procedure would be appropriate, explain to the person the risks and benefits of PCI and CABG for people with anatomically less complex disease whose symptoms are not satisfactorily controlled with optimal medical treatment. If the person does not express a preference, take account of the evidence that suggests that PCI may be the more cost-effective procedure in selecting the course of treatment
    
    
  • When either procedure would be appropriate, take into account the potential survival advantage of CABG over PCI for people with multivessel disease whose symptoms are not satisfactorily controlled with optimal medical treatment and who:
    • have diabetes or
    • are over 65 years or
    • have anatomically complex three-vessel disease, with or without involvement of the left main stem
      
      
  • when either revascularisation procedure is appropriate, explain to the person:
    • the main purpose of revascularisation is to improve the symptoms of stable angina
    • CABG and PCI are effective in relieving symptoms
    • repeat revascularisation may be necessary after either CABG or PCI and the rate is lower after CABG
    • stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures
    • there is a potential survival advantage with CABG for some people with multivessel disease

Bleeding and MI (myocardial infarction) post CABG

• study (n=36,633; Sweden) found increase in mortality risk linked to postdischarge (PD) major bleeding after CABG is substantial and similar to mortality risk linked to an MI PD
  • in the trial, 2429 (6.6%) had a major bleeding event and 2231 (6.1%) a myocardial infarction
  • investigators suggest these findings highlight the importance of meticulous consideration of bleeding risk when deciding on the optimal antithrombotic treatment after CABG

Reference:

• Detre, DM. et al.The effect of previous coronary-artery bypass surgery on the prognosis of patients with diabetes who have acute myocardial infarction. New Engl J Med 2000; 342: 989-97.
• Hlatky MA et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009 Apr 4;373(9670):1190-7.
• Serruys PW et al.Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009 Mar 5;360(10):961-72
• NICE (July 2011). Stable angina
• Björklund E, Enström P, Nielsen SJ, et al. Postdischarge major bleeding, myocardial infarction, and mortality risk after coronary artery bypass grafting. Heart Published Online First: 26 December 2023.