The epidemiology of high-risk coronary artery disease and the choice between stents and surgery

Abstract

For coronary artery disease (CAD) patients, who cannot be managed with risk factor modification and pharmacologic medical therapy, coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI), are the primary means of treatment. CABG has been considered the standard for patients who are 'high-risk,' because of anatomic or functional characteristics, but stents and modern pharmacologic adjuncts have made PCI much more competitive. Additionally, as the population ages and becomes more comorbid, some of the features of CABG that allowed 'control' of functionally high-risk patients (such as general anesthesia and heart lung bypass) become disadvantages, especially for hemodynamically unstable patients. This dissertation summarizes the only prospective, multicenter, randomized clinical trial (RCT), and prospective registry of CABG versus PCI, specific to high-risk patients: AWESOME. Previously unpublished 5-year survival data is analyzed in the context of the published AWESOME randomized trial, registry and pre-specified subset 3-year results. Qualitative summaries of all published RCTs comparing medical therapy with CABG or PCI and comparing PCI (with or without stents) with CABG are included (Appendix B). Taken together, these data allow the conclusion that PCI is not simply an alternative for high-risk patients, but that for specific patient groups, such as ST-elevation myocardial infarction (STEMI), hemodynamically compromised unstable angina/non-STEMI, and patients with major comorbidity, PCI is the preferred initial revascularization strategy in 2004.