Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease

Abstract

Objectives Determine if patients prefer multi-vessel percutaneous coronary intervention (mv-PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multi-vessel coronary artery disease (mv-CAD) despite high 1-year risk. Background Patient risk perception and preference for CABG or mv-PCI to treat medically refractory mv-CAD is poorly understood. We hypothesize that patients prefer mv-PCI instead of CABG even when quoted high mv-PCI risk. Methods 585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv-CAD. CABG or mv-PCI were presented as treatment options. Risk scenarios included variable 1-year risks of death, stroke and repeat procedures for mv-PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv-PCI over CABG across a range of quoted risks of death, stroke and repeat procedures. Results For nearly all quoted risks, patients preferred mv-PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (p<0.0001). Compared to patients, physicians chose mv-PCI less often than CABG as the risk of death and repeat procedures increased (p<0.001 and p=0.004, respectively). Conclusion Patients favor mv-PCI over CABG to treat mv-CAD, even if 1-year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv-PCI less than patients despite similarly quoted 1-year risks.

Clinical Outcomes of Treatment by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery in Patients With Chronic Kidney Disease Undergoing Index Revascularization in Ontario

“…However, despite knowledge of greater repeat revascularization procedures and even mortality associated with PCI compared with CABG, patients still frequently prefer PCI over CABG because of the perceived less invasive nature of the PCI procedure and the quicker recovery post PCI. 44 In context of such complexities, decision making in this challenging group of patients with complex multivessel coronary artery disease should be reviewed in the framework of a Heart Team to define the optimal revascularization strategy for each individual patient.…”

A new method of applying randomised control study data to the individual patient: A novel quantitative patient-centred approach to interpreting composite end points

“…Previous work in this field has explored potential limitations of composite endpoints in cardiovascular trials, demonstrating a large variation in the importance of the component end points [5,21] and differences in clinician and patient perception of certain end points [22]. Other studies have incorporated different novel methods (such as win ratio and Anderson-Gill recurrent events models) to reinterpret clinical trial data [23].…”

Patients' preferences for coronary bypass grafting or staged percutaneous coronary intervention in multi-vessel coronary artery disease

“…Although we did not formally assess the reasons why participants in our study opted for CABG or PCI, one can speculate that patients` perception of morbidity (eg sternotomy) and prolonged recovery associated with CABG might be an important factor to prefer staged PCI over CABG in our scenario. Kipp et al observed that patients' choice of revascularisation method was most influenced by the risk of death, and modestly influenced by risk of repeat procedure or stroke. This would explain at least in parts the fact, that even patients with optimal clinical results following CABG (the group of patients with ≥7 years without anginal symptoms) did not prefer CABG over PCI.…”