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{{CMG}}; '''Associate Editors-In-Chief:''' Joanna J. Wykrzykowska, MD [mailto:jwykrzyk@bidmc.harvard.edu]; Robert Sperling, MD; Brian Bigelow, MD; Roger J. Laham, MD [mailto:rlaham@bidmc.harvard.edu]


{{CMG}}<br/>
''See also the chapter on'' [[Chronic stable angina revascularization]]
'''Associate Editors-In-Chief:''' Joanna J. Wykrzykowska, MD,[mailto:jwykrzyk@bidmc.harvard.edu]; Robert Sperling, MD; Brian Bigelow, MD; Roger J. Laham, MD [mailto:rlaham@bidmc.harvard.edu]; Neil M. Gheewala, MD; Randall K. Harada, MD


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==Overview==
Multi-vessel [[coronary artery disease|coronary artery disease (CAD)]] is a disease stage in which at least two or three of the [[epicardial]] [[coronary artery|coronary arteries]] is involved with [[atherosclerosis]] of significant severity. Multivessel disease is often associated with a higher burden of [[comorbidities]], [[left ventricular dysfunction]], and [[cardiovascular]] risk. In general, [[PCI]] is preferred in patients with single or low risk two [[vessel]] disease. In contrast, [[coronary artery bypass graft surgery]] is recommended in patients with complex two [[vessel]] disease, three [[vessel]] disease and in some cases of isolated [[left main]] disease. [[Diabetic]]s with [[left anterior descending coronary artery]] disease may benefit more from [[coronary artery bypass surgery]]. The goal in the treatment of multivessel disease is to reduce [[angina]] and [[heart failure]] [[symptom]]s and to reduce a patient's subsequent risk of adverse [[cardiovascular]] events.


==Background==
==Medical Therapy==
Medical [[therapy]] consists of [[antianginal]] and [[antiplatelet]] [[medication]]s as well as high dose [[statins]]. All patients, whether they undergo [[PCI]], [[CABG]] or not, should receive optimal medical [[therapy|therapies]] to reduce [[cardiovascular]] event-risk and [[angina]]. Patients with lower-risk, [[stable CAD]] may be effectively treated by medical [[therapy]]. Medical [[therapy]] has no procedural risk or prolonged [[convalescence]], but the [[COURAGE]] Trial<ref name="pmid17387127">{{cite journal |author=Boden WE, O'Rourke RA, Teo KK, ''et al.'' |title=Optimal medical therapy with or without PCI for stable coronary disease |journal=N. Engl. J. Med. |volume=356 |issue=15 |pages=1503–16 |year=2007 |month=April |pmid=17387127 |doi=10.1056/NEJMoa070829 |url=}}</ref> showed an increased risk of [[angina]] and a decreased quality of life in patients treated with medical [[therapy]]. Moreover, 30% of the patients treated with medical [[therapy]] eventually needed [[revascularization]]. Approximately 2/3 of the study population in [[COURAGE]] had multi-vessel [[CAD]], and randomization to an initial strategy of medical [[therapy]] resulted in similar rates of death and [[MI|myocardial infarction (MI)]] to an initial strategy of [[PCI]].


Multi-vessel [[coronary artery disease|coronary artery disease (CAD)]] is associated with a higher burden of co-morbidities, [[LV dysfunction]], and cardiovascular risk. Medical decisions are frequently based on clinical trial data that are now potentially supplanted by improvements in contemporary medical, percutaneous, and surgical strategies.
==Revascularization Utilizing Coronary Artery Bypass Grafting (CABG)==
When compared to medical [[therapy]] and [[percutaneous coronary intervention]], [[CABG]] is associated with a lower [[incidence]] of recurrent [[angina]] and a lower need for repeat [[revascularization]]. It reduces late [[cardiac]] [[mortality]] in [[diabetic]] patients who received at least 1 [[internal mammary|internal mammary (IMA)]] [[graft]]. The rate of [[revascularization]] may be comparable in the era of [[drug eluting stents]], but the definitive results of ongoing trials are pending.
===CABG Versus Medical Therapy ===
Recommendations are limited by the quality of data. For instance, older trials of [[CABG]] vs. medical [[therapy]] had little use of an [[internal mammary artery|IMA]] conduit (which has greater durability) and limited use of [[ASA]], [[ACE inhibitors]], and [[statins]]. Several [[randomised controlled trial|randomized trials]] of [[CABG]] versus medical [[therapy]] support the concept of greater absolute benefit associated with [[CABG]] with respect to long-term survival in patients with more extensive or [[proximal]] [[CAD]], or in patients with impaired [[left ventricular function]]. These older data are limited by low usage of [[internal mammary artery]] (IMA) [[graft]]ing, [[antiplatelet]] agents, and a high cross-over of the medical treatment arm to [[CABG]]. [[CABG]] offers survival benefit in patients with [[left main]] [[stenosis]], multivessel disease and [[left ventricle|LV]] [[systolic dysfunction]], 3-vessel disease with [[proximal]] [[LAD]] [[stenosis]] regardless of [[left ventricular function]], and 2-vessel disease and [[left ventricle|LV]] [[systolic dysfunction]], especially with [[proximal]] disease and severe [[angina]].


==Goals of Treatment==
===CABG Versus PCI===
Many [[PCI]] vs. [[CABG]] trials did not have widespread use of [[stent]]s (either [[BMS|bare metal]] or [[DES|drug-eluting]]) or [[GP IIb/IIIa inhibitors]], and <10% of patients who were screened for trials of [[PTCA]] vs. [[CABG]] were actually randomized, and therefore represent a highly select population. With multivessel [[stent]]ing, the target [[lesion]] [[revascularization]] (TLR) rates become cumulative. [[Diabetics]] with both [[retinopathy]] and [[nephropathy]] appear to have very high major adverse [[cardiac]] events (MACE) rates with [[PCI]] (up to 50%).


Management of multi-vessel coronary artery disease focuses on:
==Revascularization by Percutaneous Coronary Intervention (PCI)==
*Reduction of adverse event risk
===PCI Versus Medical Therapy===
*Relief of angina and heart failure symptoms
The subgroup analysis of patients with [[stable CAD|stable]], multi-vessel [[CAD]] in the [[COURAGE]] trial suggested no difference in death and [[MI]] rates between [[PCI]]- and medically-treated groups.
*Delaying cardiac morbidity
===PCI Versus CABG===
One must be confident in their ability to achieve complete [[revascularization]] with [[PCI]] when offering it as an alternative to [[CABG]].
====Mortality and MI====
[[Mortality]] and nonfatal [[MI]] rates are not significantly different between the two strategies. The [[BARI]] trial showed similar 5-year survival among over 1800 patients randomized to an initial strategy of [[PTCA]] or [[CABG]] for multi-vessel [[CAD]], despite the higher rates of “complete [[revascularization]]” in the [[CABG]] arm. This trial preceded the use of [[drug eluting stents]].
====Recurrent Revascularization====
There are higher rate of recurrent [[angina]] and repeat [[revascularization]] after [[PCI]] (most trials in low-risk patients with 2-vessel disease and normal [[left ventricular function]]); this may change in future with the evolution of [[DES|drug eluting stents]]. In [[BARI]], [[CABG]] was associated with a lower rate of repeat [[revascularization]]s.


==Treatment Choices==
====Symptom Relief====
[[CABG]] has been associated with a greater relief of [[angina]]l [[symptom]]s.
====Costs====
*In comparison to [[CABG]], [[PCI]] is less invasive, has a shorter hospital stay and [[convalescence]], and has a less expensive initial hospital stay. However, the cost advantage may be lost over the long-term due to the potential need for repeat [[revascularization]].
====Trial Results====
The ARTS and [[SYNTAX]] trials showed higher primary event rates in patients randomized to [[PCI]] versus [[CABG]], driven by a higher need for [[revascularization]]. Rates of hard events, such as death and [[MI]], were similar between the treatment groups.


* Medical therapy: [[Anti-anginal]] and anti-platelet medications as well as high dose [[statins]]; new [[Antianginal|anti-anginals]]
Several trials (ARTS I, MASS II, ERACI-II, AWESOME) involving [[bare metal stents]] compared to [[CABG]] have shown similar survival rates but higher [[revascularization]] rates among patients with [[bare metal stents]] at 5 years. The [[SYNTAX]] trial, a [[randomized control trial|randomized trial]] of multi-vessel or [[left main]] [[CAD]] to [[CABG]] or [[paclitaxel]]-eluting [[stent]]s, showed higher primary adverse event rates in the [[PCI]] group (17.8% vs. 12.4% for [[CABG]]; p=0.002), largely due to an increased rate of repeat [[revascularization]] (13.5% vs. 5.9%, p<0.001).
* [[PCI|Percutaneous coronary intervention (PCI)]] with [[drug eluting stents]]
* [[CABG|Coronary artery bypass graft surgery (CABG)]]


==Advantages of Each Choice==
==Selecting a Therapeutic Strategy or Strategies==
===Medical Therapy===
===Optimal Medical Therapy===
All patients should receive optimal medical therapies to reduce cardiovascular event-risk and [[angina]]. Patients with lower-risk, stable CAD may be effectively treated by medical therapy. Medical therapy has no procedural risk or prolonged [[convalescence]], but the COURAGE Trial<ref name="pmid17387127">{{cite journal |author=Boden WE, O'Rourke RA, Teo KK, ''et al.'' |title=Optimal medical therapy with or without PCI for stable coronary disease |journal=N. Engl. J. Med. |volume=356 |issue=15 |pages=1503–16 |year=2007 |month=April |pmid=17387127 |doi=10.1056/NEJMoa070829 |url=}}</ref> showed an increased risk of [[angina]] and a decreased quality of life. Moreover, 30% of the patients eventually needed [[revascularization]].  Approximately 2/3 of the study population in COURAGE had multi-vessel CAD, and randomization to an initial strategy of medical therapy resulted in similar rates of death and [[MI|myocardial infarction (MI)]] to an initial strategy of PCI.
* Risk factor modification should be undertaken in all patients (smoking cessation, treatment of [[hypertension]], correction of [[dyslipidemia]]).
* Optimal medical [[therapy]] should be advised for all patients. Medical [[therapy]] may be an acceptable choice as the sole treatment when [[left ventricle|LV]] [[systolic]] function is normal or mildly depressed, and when the lifestyle is acceptable with medical therapy.
* [[Revascularization]] is chosen when unacceptable [[symptom]]s persist despite optimal medical therapy and when [[lesion]]s and risk factors are present for which [[revascularization]] improves [[morbidity]] and [[mortality]] compared with medical therapy (e.g. a [[LMCA|left main]] [[lesion]]). Specifically, [[revasulcarization]] is appropriate for patients with:
**[[Refractory]] [[symptom]]s
**More extensive or [[proximal]] disease
**[[Left ventricular dysfunction]]


===Revascularization===
===Scenarios Favoring CABG Over Medical Therapy to Prolong Survival===
When compared with medical therapy, [[revascularization]] (PCI or CABG) is associated with less angina, fewer [[anti-anginal]] medications, and better functional capacity and quality of life.
* [[LMCA|Left main]] [[stenosis]] >50%,
* Multivessel disease and [[left ventricle|LV]] [[systolic dysfunction]],
* 3-vessel disease with [[proximal]] [[LAD]] [[stenosis]] regardless of [[LV function]],  
* 2-vessel disease and [[left ventricle|LV]] [[systolic dysfunction]] (especially with [[proximal]] disease and severe [[angina]])


====Revascularization by CABG====
===Scenarios Favoring PCI over CABG===  
CABG is associated with a lower incidence of recurrent [[angina]] and need for repeat [[revascularization]].  It reduces late cardiac [[mortality]] in diabetic patients who received at least 1 [[internal mammary|internal mammary (IMA)]] graft. The rate of revascularization may be comparable in the era of [[drug eluting stents]] (trials are pending).
* [[CAD]] [[anatomy]] and complexity is suitable for [[PCI]] (single or two [[vessel]] disease for instance)
* Younger patients who will likely require [[CABG]] in future in order to delay the inevitable [[surgery]]
* Limited [[life-expectancy]]
* High operative risk (including: [[cerebrovascular disease]] and severe [[COPD|chronic obstructive pulmonary disease]]), or other illnesses limiting survival
* Poor [[graft]] conduits (no [[IMA]] available or poor [[vein]] quality)
* Patient prefers to avoid [[surgery]]
* In non [[diabetic]] patients with 3-vessel disease and poor [[left ventricle|LV]] [[systolic]] function, consider [[PCI]] in select patients with low-risk [[lesion]]s if complete [[revascularization]] can be achieved. The risks and benefits of lifelong [[plavix]] and risks of [[stent thrombosis]] must be discussed extensively with the patient. [[Stent]]ing is not an ideal choice for the patient who is not compliant with medication such as [[thienopyridine]]s.


Recommendations are limited by the quality of data.  For instance, older trials of CABG vs. medical therapy had little use of IMA conduit and limited use of [[ASA]], [[ACEIs]], and [[statins]].  Many PCI vs. CABG trials did not have widespread use of stents (either bare metal or drug-eluting) or [[GP IIb/IIIa inhibitors]], and <10% of patients screened for trials of [[PTCA]] vs. [[CABG]] were randomized, and therefore highly select. With multivessel stenting, TLR rates become cumulative TLR rate per lesion is triple that per patient.  [[Diabetics]] with both [[retinopathy]] and [[nephropathy]] appear to have very high major adverse cardiac events (MACE) rates with PCI (up to 50%).
===Scenarios Favoring CABG over PCI===
* In the presence of concurrent [[valvular disease]] requiring [[surgery|surgical]] repair,
* Complete functional [[revascularization]] unlikely to be achieved with [[PCI]],
* [[Lesion]]s not suitable for [[stent]]ing (low likelihood of success, high risk of [[complication]]s, high risk of [[restenosis]]),
* Patient prefers to limit number of [[revascularization]] procedures
* Patients with [[diabetes mellitus]] and multi-vessel disease may benefit more from [[CABG]] than [[PTCA]]. In general, [[CABG]] is recommended because the [[BARI]] trial showed improved survival after [[CABG]] compared with multivessel [[PCI]] if at least one [[IMA]] conduit was used, and if there were 4 or more [[lesion]]s, especially in patients with [[left ventricle|LV]] [[systolic dysfunction]]. However, the [[BARI]] trial was done in the pre- [[stent]] era and before the widespread use of [[GP IIb/IIIa inhibitors]]. It should be noted that there was no difference in survival among [[diabetic]] patients treated with [[CABG]] vs. [[PCI]] in 2 nonrandomized trials, including 5-year survival in [[BARI]] registry. Randomized data of [[diabetic]] patients using contemporary [[stent]]s and [[CABG]] techniques are lacking. The [[NHLBI]] sponsored FREEDOM trial is currently enrolling patients with [[diabetes]] and multi-vessel [[CAD]] for a comparison of [[PCI]] and [[CABG]] outcomes.


Several randomized trials of CABG versus medical therapy support the concept of greater absolute benefit of CABG in respect to long-term survival in patients with more extensive or proximal CAD or those with LV contractile dysfunction. These data were limited by low usage of IMA grafting, anti-platelet agents, and high cross-over of the medical treatment arm. Specifically, CABG offers survival benefit in patients with left main stenosis, multivessel disease and LV systolic dysfunction, 3-vessel disease with proximal LAD stenosis regardless of LV function, and 2-vessel disease and LV systolic dysfunction, especially with proximal disease and severe angina.
A collaborative analysis of data from 10 [[randomized controlled trial|randomized controlled trials]] (N= 7812) was pooled to compare effectiveness of [[CABG]] with [[PCI]] in view of long term effects on [[mortality]] in various clinical subgroups. [[PCI]] was done with [[balloon angioplasty]] in six trials and with [[bare metal stent]]s in four trials. The results showed that the long term [[mortality]] is similar with [[PCI]] and [[CABG]] in most patient subgroups who had multivessel disease. Based on this, the choice of the procedure should be made depending on patient's preference for other outcomes. [[CABG]] proved a better option in [[diabetic]]s and elderly over 65 years.<ref name="pmid19303634">{{cite journal| author=Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM et al.| title=Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9670 | pages= 1190-7 | pmid=19303634 | doi=10.1016/S0140-6736(09)60552-3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19303634  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19620152 Review in: Ann Intern Med. 2009 Jul 21;151(2):JC1-8, JC1-9] </ref>


====Revascularization by PCI====
===Scenarios Favoring a Hybrid of CABG and PCI===
The subgroup analysis of patients with stable, multi-vessel CAD in the COURAGE trial suggested no difference in death and MI rates between PCI- and medically-treated groups.
* [[Adjunctive PCI]] may be performed before after [[CABG]] in [[lesion]]s that are not amenable to [[coronary artery bypass grafting]]. This may include [[lesion]]s in very [[distal]] [[artery|arteries]], or [[lesion]]s in very small [[vessel]]s
* Due to higher [[CABG]] [[mortality]] in patients with [[Unstable angina / non ST elevation myocardial infarction|UA/NSTEMI]], a strategy of [[PCI]] to the “culprit [[artery]]” followed by [[elective]] [[revascularization]] (as needed) of the residual disease may be employed. Identification of the culprit [[artery]] requires localizing [[ECG]], [[echocardiographic]], or [[angiographic]] features ([[coronary artery|coronary]] [[thrombus]], [[ulcer|ulcerative]] [[plaque]], slow flow, a high grade [[stenosis]], or pressure wire technique).


====PCI vs. CABG====
==Technical Considerations in the Performance of Multivessel PCI==
In comparison to CABG, PCI is less invasive, has a shorter hospital stay and convalescence, is less expensive initial hospital stay; cost advantage may be lost over long-term due to need for repeat revascularization; one must be confident of their ability to achieve complete revascularization with PCI when offering it as an alternative to CABG.
* One may need to stage the procedure because of [[contrast]] load and [[radiation]] dose, as well as procedure time.
* Starting with the most challenging [[lesion]] in patients for whom [[CABG]] is an option, may be advisable to evaluate feasibility of complete [[revascularization]].
* Assessment of patient’s ability to comply with lifetime dual [[antiplatelet]] therapy is also crucial especially with [[bifurcation stenting]], long lesions and small [[vessel]]s, which are common in patients with multivessel disease where risk of [[stent thrombosis]] is highest.


The BARI trial showed similar 5-year survival among over 1800 patients randomized to an initial strategy of PTCA or CABG for multi-vessel CAD despite the higher rates of “complete revascularization” in the CABG arm.  This trial preceded the use of drug eluting stents.  However, these treatments differ in the need for repeat revascularizations and relief of angina.
==References==
 
{{Reflist|2}}
Due to higher CABG mortality in patients with [[Unstable angina / non ST elevation myocardial infarction|UA/NSTEMI]], a strategy of PCI to the “culprit artery” followed by elective, as needed, revascularization of the residual disease may be employed.  Identification of the culprit artery requires localizing [[ECG]], [[echocardiographic]], or angiographic features (coronary [[thrombus]], ulcerative plaque, slow flow, a high grade [[stenosis]], or pressure wire technique).
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The ARTS and SYNTAX trials showed higher primary event rates in patients randomized to PCI versus CABG, driven by higher need for revascularization.  Rates of hard events such as death and MI were similar between the treatment groups.


==Patient selection and initial approach==
* Risk factor modification for all patients (smoking cessation, treatment of HTN, correction of dyslipidemia).
* Optimal medical therapy should be advised for all patients.  Choose medical therapy as the sole treatment when LV systolic function is normal or mildly depressed, and when the lifestyle is acceptable with medical therapy
* Revascularization is chosen when unacceptable symptoms persist despite optimal medical therapy and when lesions and risk factors are present for which revascularization improves morbidity and mortality compared with medical therapy.  Specifically, revasulcarization is appropriate for patients with:
**Refractory symptoms
**More extensive or proximal disease
**Left ventricular contractile dysfunction
* Scenarios favoring CABG vs. medical therapy for prolonging survival:
** left main stenosis >50%,
** multivessel disease & LV systolic dysfunction,
** 3-vessel disease with proximal LAD stenosis regardless of LV function,
** 2-vessel disease & LV systolic dysfunction (especially with proximal disease & severe angina)
* Choose PCI over CABG:
** lesions suitable for PCI,
** younger patients with expected CABG in future to delay time to surgery,
** high operative risk (including: cerebrovascular disease & severe COPD), illness limiting survival,
** poor conduit (no IMA available or poor vein quality),
** patient prefers to avoid surgery
* Choose CABG over PCI:
** in the presence of associated valvular disease requiring surgical repair,
** complete functional revascularization unlikely to be achieved w/PCI,
** lesions not suitable for stenting (low likelihood of success, high risk of complications, high risk of restenosis),
** patient prefers to limit number of revascularization procedures
* CABG vs. PCI Outcomes:
** mortality & nonfatal MI rates not significantly different
** higher rate of recurrent angina & repeat revascularization after PCI (most trials in low-risk patients with 2-vessel disease & normal LV function); this may change in the near future with coated stents
** In nondiabetic patients with 3-vessel disease and poor LV systolic function, consider PCI in select patients with low-risk lesions if complete revascularization can be achieved; risk and benefits of lifelong plavix and risks of stent thrombosis must be discussed extensively
** Diabetic patients with 2- or 3-vessel disease:
*** in general, CABG is recommended as BARI trial showed improved survival after CABG compared with multivessel PCI if at least one IMA conduit was used & there were 4 or more lesions, especially in patients with LV systolic dysfunction
*** however, BARI trial was done in the pre-stent era and before the widespread use of GP IIb/IIIa inhibitors
*** there was no difference in survival among DM patients treated with CABG vs. PCI in 2 nonrandomized trials incl 5-y survival in BARI registry
*** it is possible that carefully selected patients with Diabetes can be successfully managed with PCI in the drug eluting stent era
==Technical and pharmacologic considerations==
* One may need to stage the procedure because of contrast load and radiation dose, as well as procedure time.
* Starting with the most challenging lesion in patients for whom CABG is an option, may be advisable to evaluate feasibility of complete revascularization
* Assessment of patient’s ability to comply with lifetime dual antiplatelet therapy is also crutial especially with bifurcation stenting, long lesions and small vessels, which are common in patients with multivessel disease where risk of stent thrombosis is highest
==Expected long-term outcomes==
* Resolution of angina and ischemia with both PCI and CABG and prolongation of life in selected high-risk patients with CABG
* Consider revascularization for persistent angina or ischemia with medical therapy
* Consider CABG when PCI does not successfully revascularize significant stenoses
* Consider PCI to treat unrevascularized lesions when angina or ischemia persist after CABG, or when grafts fail (15% in the first month and 80% in 10-15 years)
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Latest revision as of 19:21, 15 January 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Joanna J. Wykrzykowska, MD [2]; Robert Sperling, MD; Brian Bigelow, MD; Roger J. Laham, MD [3]

See also the chapter on Chronic stable angina revascularization

Overview

Multi-vessel coronary artery disease (CAD) is a disease stage in which at least two or three of the epicardial coronary arteries is involved with atherosclerosis of significant severity. Multivessel disease is often associated with a higher burden of comorbidities, left ventricular dysfunction, and cardiovascular risk. In general, PCI is preferred in patients with single or low risk two vessel disease. In contrast, coronary artery bypass graft surgery is recommended in patients with complex two vessel disease, three vessel disease and in some cases of isolated left main disease. Diabetics with left anterior descending coronary artery disease may benefit more from coronary artery bypass surgery. The goal in the treatment of multivessel disease is to reduce angina and heart failure symptoms and to reduce a patient's subsequent risk of adverse cardiovascular events.

Medical Therapy

Medical therapy consists of antianginal and antiplatelet medications as well as high dose statins. All patients, whether they undergo PCI, CABG or not, should receive optimal medical therapies to reduce cardiovascular event-risk and angina. Patients with lower-risk, stable CAD may be effectively treated by medical therapy. Medical therapy has no procedural risk or prolonged convalescence, but the COURAGE Trial[1] showed an increased risk of angina and a decreased quality of life in patients treated with medical therapy. Moreover, 30% of the patients treated with medical therapy eventually needed revascularization. Approximately 2/3 of the study population in COURAGE had multi-vessel CAD, and randomization to an initial strategy of medical therapy resulted in similar rates of death and myocardial infarction (MI) to an initial strategy of PCI.

Revascularization Utilizing Coronary Artery Bypass Grafting (CABG)

When compared to medical therapy and percutaneous coronary intervention, CABG is associated with a lower incidence of recurrent angina and a lower need for repeat revascularization. It reduces late cardiac mortality in diabetic patients who received at least 1 internal mammary (IMA) graft. The rate of revascularization may be comparable in the era of drug eluting stents, but the definitive results of ongoing trials are pending.

CABG Versus Medical Therapy

Recommendations are limited by the quality of data. For instance, older trials of CABG vs. medical therapy had little use of an IMA conduit (which has greater durability) and limited use of ASA, ACE inhibitors, and statins. Several randomized trials of CABG versus medical therapy support the concept of greater absolute benefit associated with CABG with respect to long-term survival in patients with more extensive or proximal CAD, or in patients with impaired left ventricular function. These older data are limited by low usage of internal mammary artery (IMA) grafting, antiplatelet agents, and a high cross-over of the medical treatment arm to CABG. CABG offers survival benefit in patients with left main stenosis, multivessel disease and LV systolic dysfunction, 3-vessel disease with proximal LAD stenosis regardless of left ventricular function, and 2-vessel disease and LV systolic dysfunction, especially with proximal disease and severe angina.

CABG Versus PCI

Many PCI vs. CABG trials did not have widespread use of stents (either bare metal or drug-eluting) or GP IIb/IIIa inhibitors, and <10% of patients who were screened for trials of PTCA vs. CABG were actually randomized, and therefore represent a highly select population. With multivessel stenting, the target lesion revascularization (TLR) rates become cumulative. Diabetics with both retinopathy and nephropathy appear to have very high major adverse cardiac events (MACE) rates with PCI (up to 50%).

Revascularization by Percutaneous Coronary Intervention (PCI)

PCI Versus Medical Therapy

The subgroup analysis of patients with stable, multi-vessel CAD in the COURAGE trial suggested no difference in death and MI rates between PCI- and medically-treated groups.

PCI Versus CABG

One must be confident in their ability to achieve complete revascularization with PCI when offering it as an alternative to CABG.

Mortality and MI

Mortality and nonfatal MI rates are not significantly different between the two strategies. The BARI trial showed similar 5-year survival among over 1800 patients randomized to an initial strategy of PTCA or CABG for multi-vessel CAD, despite the higher rates of “complete revascularization” in the CABG arm. This trial preceded the use of drug eluting stents.

Recurrent Revascularization

There are higher rate of recurrent angina and repeat revascularization after PCI (most trials in low-risk patients with 2-vessel disease and normal left ventricular function); this may change in future with the evolution of drug eluting stents. In BARI, CABG was associated with a lower rate of repeat revascularizations.

Symptom Relief

CABG has been associated with a greater relief of anginal symptoms.

Costs

  • In comparison to CABG, PCI is less invasive, has a shorter hospital stay and convalescence, and has a less expensive initial hospital stay. However, the cost advantage may be lost over the long-term due to the potential need for repeat revascularization.

Trial Results

The ARTS and SYNTAX trials showed higher primary event rates in patients randomized to PCI versus CABG, driven by a higher need for revascularization. Rates of hard events, such as death and MI, were similar between the treatment groups.

Several trials (ARTS I, MASS II, ERACI-II, AWESOME) involving bare metal stents compared to CABG have shown similar survival rates but higher revascularization rates among patients with bare metal stents at 5 years. The SYNTAX trial, a randomized trial of multi-vessel or left main CAD to CABG or paclitaxel-eluting stents, showed higher primary adverse event rates in the PCI group (17.8% vs. 12.4% for CABG; p=0.002), largely due to an increased rate of repeat revascularization (13.5% vs. 5.9%, p<0.001).

Selecting a Therapeutic Strategy or Strategies

Optimal Medical Therapy

Scenarios Favoring CABG Over Medical Therapy to Prolong Survival

Scenarios Favoring PCI over CABG

Scenarios Favoring CABG over PCI

A collaborative analysis of data from 10 randomized controlled trials (N= 7812) was pooled to compare effectiveness of CABG with PCI in view of long term effects on mortality in various clinical subgroups. PCI was done with balloon angioplasty in six trials and with bare metal stents in four trials. The results showed that the long term mortality is similar with PCI and CABG in most patient subgroups who had multivessel disease. Based on this, the choice of the procedure should be made depending on patient's preference for other outcomes. CABG proved a better option in diabetics and elderly over 65 years.[2]

Scenarios Favoring a Hybrid of CABG and PCI

Technical Considerations in the Performance of Multivessel PCI

  • One may need to stage the procedure because of contrast load and radiation dose, as well as procedure time.
  • Starting with the most challenging lesion in patients for whom CABG is an option, may be advisable to evaluate feasibility of complete revascularization.
  • Assessment of patient’s ability to comply with lifetime dual antiplatelet therapy is also crucial especially with bifurcation stenting, long lesions and small vessels, which are common in patients with multivessel disease where risk of stent thrombosis is highest.

References

  1. Boden WE, O'Rourke RA, Teo KK; et al. (2007). "Optimal medical therapy with or without PCI for stable coronary disease". N. Engl. J. Med. 356 (15): 1503–16. doi:10.1056/NEJMoa070829. PMID 17387127. Unknown parameter |month= ignored (help)
  2. Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM; et al. (2009). "Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials". Lancet. 373 (9670): 1190–7. doi:10.1016/S0140-6736(09)60552-3. PMID 19303634. Review in: Ann Intern Med. 2009 Jul 21;151(2):JC1-8, JC1-9

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