Indications for Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention in Chronic Stable Angina

Abstract

By 2000, more than 1 202 000 percutaneous and 519 000 surgical revascularization procedures were being performed annually in the United States.1 The 3 potential reasons to recommend myocardial revascularization are (1) to alleviate symptoms of myocardial ischemia, (2) to reduce the risks of future mortality, and (3) to treat or prevent morbidities such as myocardial infarction, arrhythmias, or heart failure. To minimize biases, this article focuses on data from prospective, randomized, controlled trials (RCTs) comparing coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), stents, and medical therapy for chronic coronary artery disease (CAD). The data are interpreted in the context of a conceptual framework based on patient risk, methodological characteristics of the evidence, and the occurrence of clinically relevant end points. ### Mortality Of 7 RCTs conducted 2 decades ago, only 1 found a statistically significant difference in mortality between the medical and surgical groups. A trend toward lower mortality was noted in other trials. Meta-analysis of all 7 trials,2 totaling 2649 patients, demonstrated a reduction in mortality after CABG surgery, but this was not apparent for the first 3 years of follow-up (Figure 1). Thereafter, risk reductions were significant at 5, 7, and 10 years (relative risk [RR]=0.61, 0.68, and 0.83, respectively), although 40% of patients initially assigned to medical treatment subsequently underwent CABG surgery.2 Figure 1. Overall survival after random allocation to medical treatment or coronary artery bypass graft (CABG). At 5, 7, and 10 years, 10.2%, 15.8%, and 26.4% of patients, respectively, assigned to CABG had died, compared with 15.8%, 21.7%, and 30.5% of their medically assigned counterparts. Risk reductions (RR) were significant at all 3 time points (RR=0.61, 0.68, 0.83). Reprinted from Yusuf et al2 by permission of Elsevier Science ( The Lancet . 1994;344:563–570). Reductions in the risk of death …