Major heart procedure and drug therapy found superior to less invasive approach for CAD patients

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Coronary artery bypass grafting (CABG) for advanced coronary artery disease (CAD) narrowing of the arteries supplying the heart muscle causing chest pain (angina), heart attack, or sudden death came into vogue in the 1960s. This is major heart surgery, and is most often done to alleviate angina, and (or so it was thought) to prevent heart attacks, the most common killer in the western world. Subsequent studies have found that CABG does not work very well in preventing attacks, but does reduce angina and improve quality of life.

In the 1980s a much simpler, less invasive procedure was developed: angioplasty, in which a catheter is inserted into the narrowed vessel and a balloon is expanded, crushing the fatty obstruction. Known as percutaneous coronary intervention (PCI), some studies have found it to be equivalent to CABG in successful outcomes. Both types of procedures are indicated only when medical (drug) therapy for angina is not sufficiently able to reduce symptoms. However, over the years, PCI especially has come to be an early option for doctors advising heart patients. That may now change: two studies in JAMA Internal Medicine show that PCI may be the wrong choice for many CAD patients.

The first was a meta-analysis performed by researchers from Acibadem University Medical School, Istanbul, Turkey, and Case Western Reserve Medical Center in Cleveland. They found six randomized trials including a total of 6055 patients, with an average follow-up of 4.1 years. There was a significant reduction (27 percent) in total mortality with CABG compared with PCI. There were also significant reductions (42 percent) in myocardial infarction and repeat revascularization (an amazing 71 percent!) with CABG.

The authors conclude: In patients with multivessel coronary disease, compared with PCI, CABG leads to an unequivocal reduction in long-term mortality and myocardial infarctions and to reductions in repeat revascularizations...

The second study compared PCI with medical therapy (MT) to medical therapy alone in another meta-analysis comprising five trials and 5286 patients. Myocardial ischemia (inadequate blood flow to the heart via narrowed arteries) was diagnosed in 4064 patients by exercise stress testing, nuclear or echocardiographic stress imaging, or fractional flow reserve. Follow-up duration was 5 years (median). The multinational group of researchers, led by Kathleen Stergiopoulos, MD, PhD, of the State University of New York Stony Brook School of Medicine, NY, found that there were no significant differences between the PCI + MT group, as compared with the MT alone group, in the following outcomes: overall mortality rate, nonfatal MI (heart attack), unplanned CAD procedures, nor for angina pain episodes or intensity.

These results were evaluated in an editorial by JAMA editor Mitchell H. Katz, M.D., whose main point was the relative negligence of heading towards some coronary procedure in CAD patients without first giving medical therapy a fair trial: [W]hen PCI was first introduced in the 1980s it was said that it would replace CABG, in current practice, it is being used instead of medical therapy, often before medical therapy is even attempted. This is particularly problematic because some patients who are unwilling to have surgery may agree to a percutaneous procedure, even though it may have a greater mortality risk than CABG and may cause them greater harm than medical therapy. They might make a different decision if they knew that medical therapy was a viable option.