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Abstract

Ever since the introduction of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in 1964 and 1977, respectively, these complementary strategies of revascularization for coronary artery disease have been used extensively. Many randomized clinical trials have compared both strategies During the last decade the introduction of drug eluting stents, together with antiplatelet and antithrombotic treatments has improved the outcome of PCI by reducing the number of repeat revascularizations. Coronary bypass surgery has improved as well by using more arterial grafts, better perioperative care and optimizing medical treatment postoperatively. CABG surgery remains superior to PCI and medical treatment for the long term relief of angina for patients with complex coronary artery disease with little difference in overall costs between PCI (with the need for repeat procedures) and CABG.The SYNTAX trial randomized 1800 patients in 85 centers with multivessel and/or left main coronary disease to percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Approximately two-thirds of the left main subjects with a SYNTAX score of 32 or below had comparable clinical overall outcomes (including lower mortality) achieved with PCI at 5 years follow-up which may justify the use of PCI with DES in these subjects. However, these subgroup analyses were post hoc and underpowered, and as such must be considered hypothesis-generating.The ongoing EXCEL trial is expected to provide a better answer on the optimal treatment strategy for left main disease patients.Outcomes after revascularization with either PCI or CABG are often worse in diabetic compared to nondiabetic patients.Patients with diabetes that undergo PCI have higher rates of restenosis and lower rates of event-free survival than nondiabetic patients. Although diabetes does not appear to affect in-hospital mortality after PCI and CABG, short-and long-term survival after PCI and CABG are significantly reduced in diabetic patients. The SYNTAX trial included 452 patients with diabetes. At five-year follow-up, the rate of repeat revascularization of patients undergoing PCI (n = 231) was higher in patients with diabetes (29 versus 19 percent). Mortality was also increased in the diabetic population Coronary artery bypass surgery and PCI The are complimentary. In patients with severe three-vessel coronary artery disease and left main disease coronary bypass surgery with at least one arterial graft is still the most effective treatment at this moment and the therapy of choice. In patients with less severe coronary artery disease PCI is the more attractive therapy due to its limited invasiveness.To select the most optimal treatment strategy for individual patients with stable complex coronary artery disease, multidisciplinary decision-making has gained more emphasis over the recent years. However, so called Heart Teams have not been widely implemented. Yet, decision-making has shown to remain suboptimal. There is large variability in...