Comparative effectiveness of revascularization strategies in stable ischemic heart disease: current perspective and literature review

Abstract

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple randomized controlled trials and observational studies have compared the impact of the two modalities on the patients’ quality of life, mortality and morbidity, as well as the cost–effectiveness of these modalities in different clinical setting. CABG is the preferred strategy for revascularizations in patients with multi-vessel disease, especially in those with higher risk secondary to associated diabetes, left ventricular dysfunction or more complex lesions. PCI is a reasonable revascularization modality in patients with ischemia and single or low-risk multi-vessel disease and those with unprotected left main with low complexity anatomy. Compared with PCI, CABG is associated with less repeat revascularization, better quality of life and improved survival in high-risk patients. Although CABG is associated with higher cost, it is probably associated with a reasonable cost per quality-adjusted life-year gained in many patients. Therefore, CABG will often be a cost-effective strategy, especially in patients with high angiographic complexity and/or diabetes.

Keywords::

• coronary artery bypass grafting
• drug-eluting stents
• major adverse cardiovascular and cerebrovascular event
• multi-vessel disease
• percutaneous coronary intervention
• unprotected left main disease

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • In determining the revascularization strategy for patients with coronary artery disease, multiple factors should be considered before deciding the optimal modality.

• • The complexity of the disease, the associated risk factors, especially diabetes, and the presentation all should play a role in decision-making.

• • Percutaneous coronary intervention is probably reasonable option for non-diabetic patients with low-risk multi-vessel disease or patient with isolated left main (LM) disease or low- to intermediate-risk LM disease.

• • Coronary artery bypass grafting (CABG) is the preferable intervention for patient with multi-vessel disease and high complexity lesion, diabetes, LM if associated with high complexity anatomy.

• • Further evaluation is needed to evaluate the appropriate revascularization strategy in different age group.

• • Although CABG is associated with higher cost early and probably on the long term, it is associated with reasonable cost per quality-adjusted life years gained, and therefore CABG will often be a cost-effective strategy, especially in patients with high angiographic complexity and/or diabetes.

• • CABG is associated with higher quality of life outcomes than percutaneous coronary intervention. This difference is more prominent in patients treated with bare metal stent. But it is still observed to a smaller extent in those treated with drug-eluting stents.

Notes