Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease

Abstract

The purpose of this study was to evaluate long-term survival benefits of bypass surgery and angioplasty versus medical therapy in 9263 patients at Duke University Medical Center between 1984 and 1990 with coronary artery disease confirmed by cardiac catheterization to involve one, two, or three vessels. Clinical data were prospectively entered into an established cardiovascular database, and annual follow-up was 97% complete for a mean interval of 5.3 years and a maximal interval of 10 years. Outcomes were analyzed with the Coronary Artery Surgery Study "method A" to define patient groups treated by medicine (n = 2449), angioplasty (n = 2924), or bypass surgery (n = 3890). Differences among treatment groups in baseline characteristics were adjusted by Cox proportional hazard models. The anatomic severity of coronary artery stenosis best defined survival benefit from bypass surgery and angioplasty versus medical treatment. One or both interventional treatments provided better long-term survival than did medical treatment for all levels of disease severity. All patients with single-vessel disease, except those with at least 95% proximal left anterior descending stenosis, benefited from angioplasty versus bypass. All patients with three-vessel disease and those two-vessel patients with > or = 95% proximal left anterior descending stenosis benefited from bypass surgery versus angioplasty. All other patients with two-vessel disease and those with > or = 95% proximal left anterior descending stenosis only had similar survival with either interventional treatment. The absolute survival benefit was greatest for patients with severe three-vessel disease treated with bypass surgery.

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

“…For example, long-term survival with 97% follow-up for 9263 patients with CAD has been reported by the Duke Registry. 24 Over a spectrum of baseline risk, CABG was associated with improved long-term outcomes in comparison with medical therapy among patients in moderateand high-risk strata, and PTCA was superior to medical therapy only among low-risk strata. 24 Compared with PTCA, CABG was associated with improved outcomes among highrisk strata (chiefly those with involvement of the proximal left anterior descending artery), and PTCA was superior to CABG among low-risk patients.…”

Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting

“…RCTs comparing PCI and CABG for multivessel CAD did not demonstrate a statistically significant survival difference (5-16), with the exception of patients with diabetes (17).…”

“…This patient population is one of the most controversial, from an outcome perspective. Early registry studies comparing PTCA and CABG showed a trend toward improved survival following surgical revascularization in this patient population (17)(18)(19)(20)(21). However, RCTs from the PCI era, which used stents and GP IIb/IIIa inhibitors, are conflicting.…”

“…These data extend our knowledge regarding the most appropriate treatment strategy for specific population(s) of patients with CAD, especially with regard to the survival benefit of catheter-based revascularization compared with MM. Prior registry studies (17,20) showed improved long-term outcomes following PTCA compared with MM in specific patient populations. The Emory-Coronary Artery Surgery Study (CASS) (20) demonstrated a survival advantage in patients with impaired left ventricular function (ejection fraction lower than 50%) and two-vessel disease who were treated with PCI compared with MM.…”

“…However, the subgroup of patients with pLAD did not demonstrate a significant survival difference. Data from the Duke registry are suggestive of PTCA superiority in long-term outcomes, compared with MM, in a low-risk stratum of CAD patients (17). The major concern about the results of all of these aforementioned registry trials and studies is their nonrandomized nature.…”