Although coronary artery bypass grafting (CABG) remains the treatment of choice for certain types of coronary artery disease (CAD), percutaneous coronary intervention (PCI)—particularly coronary angioplasty with stenting—has become the most popular nonmedical treatment approach to CAD. Some have speculated that, with the advent of drug-eluting stents (DESs), PCI will replace CABG entirely. However, the complete disappearance of CABG is both unlikely and unwarranted, for several reasons. Published randomized trials of CABG, PCI, and medical approaches to CAD compared only highly selected subgroups of patients because of strict exclusion criteria that often favored the PCI cohorts. Therefore, their results do not constitute sufficient evidence for the superiority of PCI over CABG in all CAD patients requiring revascularization. As PCI indications broaden to include more complex lesions and more high-risk patients, outcomes will not remain as favorable. In addition, although PCI is less invasive than surgery, CABG offers more complete revascularization and better freedom from repeat revascularization. Furthermore, no long-term patency data on DESs yet exist, whereas excellent 10- and 20-year patency rates have been reported for the left internal mammary artery-to-left anterior descending artery graft used in most CABG procedures. While PCI has been changing, CABG has not been stagnant; recently, advances in many aspects of the CABG procedure have improved short- and long-term outcomes in CABG patients. Both CABG and PCI technologies will continue to advance, not necessarily exclusive of one another, but no data yet exist to suggest that DESs will render CABG obsolete any time soon.
Angioplasty, transluminal, percutaneous coronary; coronary artery bypass; stents
Objectives: To compare initial and one year costs of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in the stent or surgery trial.
Design: Prospective, unblinded, randomised trial.
Setting: Multicentre study.
Patients: 988 patients with multivessel disease.
Interventions: CABG and stent assisted PCI.
Main outcome measures: Initial hospitalisation and one year follow up costs.
Results: At one year mortality was 2.5% in the PCI arm and 0.8% in the CABG arm (p = 0.05). There was no difference in the composite of death or Q wave myocardial infarction (6.9% for PCI v 8.1% for CABG, p = 0.49). There were more repeat revascularisations with PCI (17.2% v 4.2% for CABG). There was no significant difference in utility between arms at six months or at one year. Quality adjusted life years were similar 0.6938 for PCI v 0.6954 for PCI, Δ = 0.00154, 95% confidence interval (CI) −0.0242 to 0.0273). Initial length of stay was longer with CABG (12.2 v 5.4 days with PCI, p < 0.0001) and initial hospitalisation costs were higher (£7321 v £3884 for PCI, Δ = £3437, 95% CI £3040 to £3848). At one year the cost difference narrowed but costs remained higher for CABG (£8905 v £6296 for PCI, Δ = £2609, 95% CI £1769 to £3314).
Conclusions: Over one year, CABG was more expensive and offered greater survival than PCI but little added benefit in terms of quality adjusted life years. The additional cost of CABG can be justified only if it offers continuing benefit at no further increase in cost relative to PCI over several years.
coronary angioplasty; coronary bypass surgery; health care cost
Multivessel coronary artery disease is more often treated either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) with stenting. The advent of drug-eluting stent (DES) has changed the revascularization strategy, and caused an increase in the use of DES in multivessel disease (MVD), with reduced rate of repeat revascularization compared to conventional bare metal stent. The comparative studies of DES-PCI over CABG have shown comparable safety; however, the rate of major adverse cerebrovascular and cardiac events and repeat revascularization was significantly higher with DES-PCI at long term. In diabetic patients with MVD, concern of repeat revascularization with DES-PCI is persistent. More recent, one-year economic outcomes have reported that the CABG is favored among patients with high angiographic complexity. The higher rate of repeat revascularization with DES-PCI in MVD would lead to increased economic burden on patient at long term besides bearing high cost of DES. In diabetic MVD patients, CABG is associated with having better clinical outcomes and being more cost-effective approach when compared to DES-PCI at long term.
Coronary artery bypass grafting (CABG) is the optimal treatment option for left main coronary artery disease (LMCAD). However, LMCAD remains a constant topic of discussion between cardiac surgeons and interventional cardiologists. The aim of this study was to assess the efficacy of LMCAD treatments by comparing the mid-term outcomes of CABG and percutaneous coronary intervention (PCI) using bare metal stents or drug-eluting stents (DESs).
Materials and Methods
The study population was comprised of 199 consecutive patients admitted with unprotected LMCAD. All of the patients were assigned to PCI (88 patients) or CABG (111 patients). The primary clinical end point indicated death, stroke of acute coronary syndrome (ACS).
Patients assigned to PCI were at higher operative risk than patients scheduled for CABG (6.49±4.09 vs. 4.81±2.67, p=0.0032). Comparison of the group that received DESs with the CABG group did not reveal any differences in major adverse cardio-cerebral events (MACCE) occurrence (21% vs. 16%, p=NS). Patients in the CABG and PCI groups died with similar frequency (11% vs. 16%, p=NS). The mortality rate in the CABG group was higher than among those treated with DES (11% vs. 3%, p=0.049). The rate of ACS was higher in the PCI group than in the CABG group (13% vs. 4%, p=0.016).
Despite the fact that patients treated with PCI were at higher operative risk, PCI with DES was shown to be comparable to CABG in terms of mortality, stroke and ACS. However, the frequency of repeat revascularizations remains a constant concern with PCI.
Left main; PCI; DES; CABG
Treatment options for coronary revascularisation include percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In the ‘synergy between PCI with TAXUS and cardiac surgery (SYNTAX)’ trial, PCI and CABG using state-of-the-art techniques (using paclitaxel-eluting stents and arterial grafts, respectively) were compared in the treatment of complex coronary artery disease. In Syntax, PCI was inferior to CABG at one year, entirely due to an increased repeat intervention rate. We hypothesised that the use of a superior drug-eluting stent system could reduce the need for repeat intervention. (Neth Heart J 2010;18:451–3.)
Percutaneous Coronary Intervention; Coronary Artery Bypass Surgery; Drug Eluting Stents; Coronary Artery Disease; Meta-analysis
Drug-eluting stents (DES) may promote percutaneous coronary intervention (PCI) procedures in patients traditionally referred for coronary artery bypass graft (CABG) surgery and may save money.
The purpose of the present study was to quantify the potential shift from CABG surgery to multivessel PCI in the DES era and to model the economic consequences.
Based on predefined criteria, the feasibility of PCI was evaluated in patients with multivessel coronary artery disease who underwent CABG surgery before the availability of DES at the Centre Hospitalier de l’Université de Montréal’s Notre-Dame Hospital (Montreal, Quebec). Modelling was used to evaluate the potential cost savings using multivessel PCI instead of CABG surgery. Equal one-year outcomes in both groups were assumed, with the exception of a 10% repeat revascularization (RR) rate in the DES group and a 4% RR rate in the CABG group. The impact of those assumptions was evaluated using 1000 Monte Carlo simulations.
The authors retrospectively evaluated that, of 289 patients who underwent CABG without concomitant valve surgery between January and December 2003, only 22 patients (8%) were good candidates for multivessel DES implantation. The procedures would have involved an average of 3.6 DES per patient. The average cost per revascularization procedure was $14,402 with surgery and $11,220 for multivessel DES implantation (using $2,200 DES), leading to a savings of $3,182 per patient. However, after including RR procedures, PCI would only have been associated with savings of $812 per surgery avoided. Monte Carlo analysis revealed that surgery may be less expensive than PCI in 36% of patients.
Most patients who underwent CABG surgery in 2003 were retrospectively judged to be ineligible for multivessel PCI with DES. In the rare eligible patient, multivessel PCI with DES is not expected to produce savings to health care costs in Canada unless the DES purchase cost continues to decrease.
Coronary artery bypass grafting surgery; Drug-eluting stents; Economic analysis; Multivessel disease; Percutaneous coronary intervention
Coronary artery bypass grafting (CABG) has been considered the standard therapy for unprotected (nonrevascularized) left main coronary disease (ULM). However, increasing experience with ULM percutaneous coronary intervention (PCI) has resulted in high procedural success and favorable early and late clinical outcomes. In particular, reduction in clinical restenosis with drug-eluting stents, evolution of procedural technique, and demonstration of favorable outcomes from comparative trials with CABG have promoted consideration of PCI as an alternative revascularization strategy in selected patients with ULM disease. This review summarizes the results from comparative studies examining PCI versus CABG for ULM disease, discusses changing indications for ULM PCI and identifies outstanding issues that must be considered before further advancing treatment recommendations.
Left main coronary artery; Stents; Bypass surgery; Drug-eluting stents; Guidelines; SYNTAX trial; Revascularization
Although there have been several studies that compared the efficacy of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), the impact of off-pump CABG (OPCAB) has not been well elucidated. The objective of the present study was to compare the outcomes after PCI, on-pump CABG (ONCAB), and OPCAB in patients with multivessel and/or left main disease.
Among the 9877 patients undergoing first PCI using bare-metal stents or CABG who were enrolled in the CREDO-Kyoto Registry, 6327 patients with multivessel and/or left main disease were enrolled into the present study (67.9 ± 9.8 years old). Among them, 3877 patients received PCI, 1388 ONCAB, and 1069 OPCAB. Median follow-up was 3.5 years.
Comparing PCI with all CABG (ONCAB and OPCAB), propensity-score-adjusted all-cause mortality after PCI was higher than that CABG (hazard ratio (95% confidence interval): 1.37 (1.15–1.63), p < 0.01). The incidence of stroke was lower after PCI than that after CABG (0.75 (0.59–0.96), p = 0.02). CABG was associated with better survival outcomes than PCI in the elderly (interaction p = 0.04). Comparing OPCAB with PCI or ONCAB, propensity-score-adjusted all-cause mortality after PCI was higher than that after OPCAB (1.50 (1.20–1.86), p < 0.01). Adjusted mortality was similar between ONCAB and OPCAB (1.18 (0.93–1.51), p = 0.33). The incidence of stroke after OPCAB was similar to that after PCI (0.98 (0.71–1.34), p > 0.99), but incidence of stroke after ONCAB was higher than that after OPCAB (1.59 (1.16–2.18), p < 0.01).
In patients with multivessel and/or left main disease, CABG, particularly OPCAB, is associated with better survival outcomes than PCI using bare-metal stents. Survival outcomes are similar between ONCAB and OPCAB.
Coronary artery bypass grafting; Percutaneous coronary intervention; Off-pump
Aims: To investigate whether, over the 21 year period 1980–2001, there had been a reduction in the risk of repeat revascularisation or death from cardiovascular disease in the cohort of all patients who were treated by coronary revascularisation in Western Australia.
Setting: State of Western Australia.
Patients: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001.
Design: Cohort study.
Main outcome measures: Risk of repeat coronary artery revascularisation procedures (CARP) and risk of death from cardiovascular disease after first CARP.
Results: After a CABG procedure, the two year risk of repeat revascularisation remained low (less than 2%) across the period 1980–2001. For PCI, however, this risk declined significantly from 33.6% in 1985–9 to 12.4% in 2000–1. The risk of death from cardiovascular disease after a CARP declined by about 50% between 1985 and 2001.
Conclusions: Outcomes such as the risk of repeat revascularisation and the risk of death from cardiovascular disease have improved significantly for patients who underwent CARPs across the period 1980–2001. This has occurred despite an increasing trend in first CARP rates among older people and those with a recent history of myocardial infarction.
coronary artery bypass; angioplasty; survival analysis
The choice of optimal revascularization strategy in patients with coronary artery disease (CAD) is becoming more challenging lately, due to recent advances in percutaneous coronary intervention (PCI) and coronary artery bypass grafting surgery (CABG). On one hand, drug–eluting stents (DES) have emerged as a solution to the problem of restenosis after balloon angioplasty or bare–metal stent implantation, which was responsible for a higher rate of events (mainly repeat revascularization) in relation to CABG. On the other hand, off–pump bypass techniques and minimally invasive grafting of the left anterior descending artery appear to be safe and efficacious alternatives to traditional, on–pump CABG. Available literature includes studies outdated by current technologies, leaving the dilemma of best revascularization strategy unanswered in the general CAD population, but also in high–risk groups, such as diabetics and patients with chronic kidney disease. A number of ongoing trials, especially designed for this purpose, are set to end the debate, providing headto– head comparisons between DES–assisted PCI and contemporary bypass surgery.
percutaneous coronary intervention; coronary artery bypass grafting; drug-eluting stents; pump bypass surgery
Based on data comparing coronary-artery bypass grafting (CABG) with medical therapy, the current guidelines recommend CABG as the treatment of choice for patients with left main coronary artery (LMCA) disease. Percutaneous coronary intervention (PCI) can be selectively performed in patients who are candidates for revascularization but who are ineligible for CABG. Current evidence indicates that stenting results in mortality and morbidity rates compared favorably with those seen after CABG. Data from several extensive registries and a large clinical trial may have prompted many interventional cardiologists to choose PCI with stenting as an alternative treatment option for such patients. In addition, these data may inform future guidelines and support the need for well-designed, adequately powered, prospective, randomized trials comparing the two revascularization strategies.
Bypass surgery; stents; coronary disease
Evidence about the efficacy of statin treatment among patients after percutaneous coronary intervention (PCI) is very limited. The rapid advancement in PCI technology and near universal use of adjunctive cardioprotective medications make it necessary to formally assess the effect of statin therapy on cardiac events after PCI.
This was a multicenter prospective cohort study
Patients who received stent implantation and survived to hospital discharge from the National Heart, Lung, and Blood Institute Dynamic Registry from 2004 to 2006 formed the study cohort. Patients with cardiogenic shock, in-hospital adverse events [including myocardial infarction and coronary artery bypass graft surgery (CABG)], liver disease, renal disease, alcoholism, or drug abuse were excluded. The occurrences of death, CABG, and repeat PCI, and repeat revascularization were collected over 1-year follow-up.
Of the 3227 patients evaluated, 2737 (85%) were prescribed a statin at discharge. By 1-year follow-up, incident events were 98 deaths, 44 CABG, 290 repeat PCI procedures, and 328 repeat revascularizations. After propensity score adjustment, postdischarge statin therapy was associated with lower risks of death [hazard ratio (HR)λ=λ0.58, 95% confidence interval (CI): 0.36–0.93, Pλ=λ0.02], CABG (HRλ=λ0.49, 95% CI: 0.24–1.00, Pλ=λ0.05), and repeat revascularization (HRλ=λ0.74, 95% CI: 0.56–1.00, Pλ=λ0.05).
These results support the routine use of statin therapy after PCI.
mortality; propensity score; repeat revascularization; stent
Patients with peripheral arterial disease (PAD) undergoing percutaneous coronary intervention (PCI) are at high risk for adverse cardiovascular events. Trends over time in outcomes with advances in PCI and medical therapy are unknown. We evaluated 866 patients with PAD in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry undergoing PCI according to treatment eras: the early bare metal stent (BMS) era (Wave 1: 1997-1998, n=180), the BMS era (Waves 2 and 3; 1999 and 2001-2002; n=339), and the drug-eluting stent (DES) era (Waves 4 and 5: 2004 and 2006; n=347). We compared in-hospital and 1-year outcomes by recruitment era. In-hospital coronary artery bypass graft surgery (CABG) rates were significantly lower in the later eras (3.9%, 0.9%, 0.6%, early BMS, BMS, and DES eras respectively, ptrend=0.005), and an increasing percentage of patients were discharged on aspirin, beta blockers, statins, and thienopyridines (all ptrend<0.001). Cumulative 1-year event rates in patients with PAD in the early BMS era, BMS era, and DES era of death were 13.7%, 10.5%, and 9.8% (ptrend = 0.21), of myocardial infarction (MI) were 9.8%, 8.8%, and 10.0% (ptrend = 0.95), and repeat revascularization were 26.8%, 21.0%, and 17.2% (ptrend = 0.008). The 1-year adjusted hazard ratios (HR) of adverse events in patients with PAD using the early BMS era as the reference are as follows: Death: BMS era HR=0.84 (95% CI 0.46-1.55, p=0.58) and DES era HR=1.35 (95% CI 0.71-2.56, p=0.36); MI: BMS era HR=0.89 (95% CI 0.48-1.66, p=0.72) and DES era HR=1.02 (95% CI 0.55-1.87, p=0.95); and repeat revascularization: BMS era HR=0.63 (95% CI 0.41-0.97, p=0.04) and DES era HR=0.46 (95% CI 0.29-0.73, p=0.001). In conclusion, despite significant improvements in medical therapy and a reduction in repeat revascularization over time, patients with PAD who undergo PCI have a persistent high rate of death and MI.
Peripheral arterial disease; stents; catheterization
Rheumatoid arthritis (RA) is associated with an increased prevalence of coronary artery disease (CAD). We investigated the presenting symptoms of CAD, coronary anatomy (single vs. multivessel CAD), and treatment among a group of subjects undergoing percutaneous coronary intervention (PCI) with angioplasty and/or stenting.
We evaluated a retrospective cohort of 43 RA subjects and 43 matched non-RA subjects undergoing PCI at 2 academic referral centers. RA subjects were matched to non-RA subjects on age, gender, history of coronary artery bypass grafting (CABG), date of PCI and Interventional Cardiologist. We compared cardiac risk factors, presentation, treatment and outcomes.
The mean age of the study cohort was 71 ± 10 years, and the distribution of traditional cardiac risk factors was similar in the subjects with RA compared to the matched non-RA subjects (all P values > 0.05). Seventy-four percent of subjects with RA compared to 67% of those without RA presented with an acute coronary syndrome prior to PCI (P = 0.48). All subjects in this cohort undergoing PCI had at least one stenosis in a major epicardial vessel and similar percentages of subjects with RA (44%) and without RA (40%) had multivessel CAD (P = 0.66). The administration of cardiac medications both at PCI and at hospital discharge was not different among subjects with RA compared to matched non-RA subjects.
Among this cohort with significant CAD undergoing PCI, clinical characteristics, presentation, severity of CAD, treatment modalities and outcomes were similar in subjects with RA and well-matched non-RA subjects.
Redo coronary artery bypass grafting surgery (CABG) is associated with a higher risk of mortality than the first operation. However, the impact of percutaneous coronary intervention (PCI) on the outcome in such patients is currently unclear. We evaluated the in-hospital and six-month clinical outcomes of post-CABG patients who underwent PCI in our center.
Between April 2008 and July 2009, 71 post-CABG patients (16 women and 55 men) underwent 110 stent implantations (74% drug-eluting stents) for 89 lesions. Sixty percent of the PCI procedures were performed on the native coronary arteries, 32% on graft arteries, and 8% on both types of vessels. Major adverse cardiac events (MACE) were recorded in hospital and at six months’ follow-up.
The procedural success rate was 93%, and the in-hospital MACE rate was 5.6 % (1 death, 3 myocardial infarctions). At 6 months, the incidence of MACE was 5.6% (no death or myocardial infarction, but 4 target lesion revascularizations) and 4 (5.6 %) in-stent restenoses. There was no statistically significant difference in the comparison of MACE between the patients treated in either native arteries or in the grafts (15% vs.12%, p value = 0.8). According to the univariate analysis, hypertension and the use of the bare metal stent vs. the drug-eluting stent were the significant predictors of MACE, whereas the multivariate analysis showed that only hypertension (OR = 3.7, 95% CI 3.4–4, p value < 0.048) was the independent predictor of MACE. The mean of the left ventricular ejection fraction had no effect on the incidence of MACE (p value = 0.9). The multivariate analysis showed hypertension (p value < 0.048) and the use of the bare metal stent (p value < 0.018) were the independent predictors of MACE. The chronic total occlusion (CTO) (p value < 0.01) was the independent predictor of the success rate. The prevalence of diabetes had no impact on the incidence of MACE according to the univariate analysis (p value = 0.9). Our multivariate analysis showed that hypertension and the use of the bare metal stent were the independent predictors of MACE and that chronic total occlusion was the independent predictor of the procedural failure rate.
PCI is preferable to redo CABG for post-CABG patients. The independent predictors of MACE were hypertension and bare metal stents.
Angioplasty; Coronary artery bypass; Treatment outcome; Reoperation
Comparative effectiveness of interventional treatment strategies for the very elderly with acute coronary syndrome remains poorly defined due to study exclusions. Interventions include percutaneous coronary intervention (PCI), usually with stents, or coronary artery bypass grafting (CABG). The elderly are frequently directed to PCI because of provider perceptions that PCI is at therapeutic equipoise with CABG and that CABG incurs increased risk. We evaluated long-term outcomes of CABG versus PCI in a cohort of very elderly Medicare beneficiaries presenting with acute coronary syndrome.
Using Medicare claims data, we analyzed outcomes of multivessel PCI or CABG treatment for a cohort of 10,141 beneficiaries age 85 and older diagnosed with acute coronary syndrome in 2003 and 2004. The cohort was followed for survival and composite outcomes (death, repeat revascularization, stroke, acute myocardial infarction) for three years. Logistic regressions controlled for patient demographics and comorbidities with propensity score adjustment for procedure selection.
Percutaneous coronary intervention showed early benefits of lesser morbidity and mortality, but CABG outcomes improved relative to PCI outcomes by three years (p < 0.01). At 36 months post-initial revascularization, 66.0% of CABG recipients survived (versus 62.7% of PCI recipients, p < 0.05) and 46.1% of CABG recipients were free from composite outcome (versus 38.7% of PCI recipients, p < 0.01).
In very elderly patients with ACS and multivessel CAD, CABG appears to offer an advantage over PCI of survival and freedom from composite endpoint at three years. Optimizing the benefit of CABG in very elderly patients requires absence of significant congestive heart failure, lung disease, and peripheral vascular disease.
Over the last 20 years, percutaneous transluminal balloon coronary angioplasty (PTCA), bare metal stents (BMS) and drug eluting stents (DES) succeeded each other as catheter-based treatments for coronary artery disease (CAD). We present an overview of randomised trials comparing these interventions with each other and with medical therapy in patients with nonacute CAD.
We searched Medline for trials contrasting at least two of the aforementioned interventions. Outcomes of interest were death, myocardial infarction (MI), coronary artery bypass grafting (CABG), target lesion or vessel revascularisation (TLR/TVR), and any revascularisation. Random effects meta-analyses summarised head-to-head (direct) comparisons, and network meta-analyses integrated direct and indirect evidence.
61 eligible trials (25 388 patients) investigated 4 of 6 possible comparisons between the 4 interventions. No trials directly compared DES with medical therapy or PTCA. In all direct or indirect comparisons, succeeding advancements in PCI did not yield detectable improvements in deaths and MI. The risk ratio for indirect comparisons between DES and medical therapy was 0·96 (95% confidence interval: 0·60, 1·52) for death and 1·15 (0·73, 1·82) for MI. In contrast, there were sequential significant reductions in TLR/TVR with BMS compared to PTCA and with DES compared to BMS. The risk ratio for the indirect comparison between DES and PTCA for TLR/TVR was 0·30 (0·17, 0·51).
Sequential innovations in the catheter-based treatment of nonacute CAD showed no evidence of an impact on death or MI when compared with medical therapy.
During the past 2 decades, percutaneous coronary intervention (PCI) has increased dramatically compared with coronary artery bypass grafting (CABG) for patients with coronary artery disease. However, although the evidence available to all practitioners is similar, the relative distribution of PCI and CABG appears to differ among hospitals and regions.
Methods and Results
We reviewed the published data from the mandatory New York State Department of Health annual cardiac procedure reports issued from 1994 through 2008 to define trends in PCI and CABG utilization in New York and to compare the PCI/CABG ratios in the metropolitan area to the remainder of the State. During this 15-year interval, the procedure volume changes for CABG, for all cardiac surgeries, for non-CABG cardiac surgeries, and for PCI for New York State were −40%, −20%, +17.5%, and +253%, respectively; for the Manhattan programs, the changes were similar as follows: −61%, −23%, +14%, and +284%. The average PCI/CABG ratio in New York State increased from 1.12 in 1994 to 5.14 in 2008; however, in Manhattan, the average PCI/CABG ratio increased from 1.19 to 8.04 (2008 range: 3.78 to 16.2). The 2008 PCI/CABG ratios of the Manhattan programs were higher than the ratios for New York City programs outside Manhattan, in Long Island, in the northern counties contiguous to New York City, and in the rest of New York State; their averages were 5.84, 5.38, 3.31, and 3.24, respectively. In Manhattan, a patient had a 56% greater chance of receiving PCI than CABG as compared with the rest of New York State; in one Manhattan program, the likelihood was 215% higher.
There are substantial regional and statewide differences in the utilization of PCI versus CABG among cardiac centers in New York, possibly related to patient characteristics, physician biases, and hospital culture. Understanding these disparities may facilitate the selection of the most appropriate, effective, and evidence-based revascularization strategy. (J Am Heart Assoc. 2012;1:e001446 doi: 10.1161/JAHA.112.001446.)
CABG; myocardial revascularization; PCI; PCI-CABG ratio
Drug-eluting stents (DES) are considered the treatment of choice for most patients with obstructive coronary artery disease when percutaneous intervention (PCI) is feasible. However, stent thrombosis seems to occur more frequently with DES and occasionally is associated with resistance to anti-platelet drugs. We have experienced a case of recurrent stent thrombosis in a patient with clopidogrel resistance. A 63-year-old female patient suffered from acute myocardial infarction and underwent successful PCI of the left anterior descending coronary artery (LAD) with two DESs. She was found to be hyporesponsive to clopidogrel and was treated with triple anti-platelet therapy (aspirin 100 mg, clopidogrel 75 mg, and cilostazol 200 mg daily). Three days after discharge, she developed chest pain and was again taken to the cardiac catheterization laboratory, where coronary angiography (CAG) showed total occlusion of the mid-LAD where the stent had been placed. After intravenous administration of a glycoprotein IIb/IIIa inhibitor, balloon angioplasty was performed, resulting in Thrombolysis In Myocardial Infarction (TIMI) III antegrade flow. The next day, however, she complained of severe chest pain, and the electrocardiogram showed marked ST-segment elevation in V1-V6, I, and aVL with complete right bundle branch block. Emergent CAG revealed total occlusion of the proximal LAD due to stent thrombosis. She was successfully treated with balloon angioplasty and was discharged with triple anti-platelet therapy.
Thrombosis; Stents; Clopidogrel
Sirolimus-eluting stents have recently been shown to reduce the risk of restenosis among patients who undergo percutaneous coronary intervention (PCI). Given that sirolimus-eluting stents cost about 4 times as much as conventional stents, and considering the volume of PCI procedures, the decision to use sirolimus-eluting stents has large economic implications.
We performed an economic evaluation comparing treatment with sirolimus-eluting and conventional stents in patients undergoing PCI and in subgroups based on age and diabetes mellitus status. The probabilities of transition between clinical states and estimates of resource use and health-related quality of life were derived from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Information on effectiveness was based on a meta-analysis of randomized controlled clinical trials (RCTs) comparing sirolimus-eluting and conventional stents.
Cost per quality-adjusted life year (QALY) gained in the baseline analysis was Can$58 721. Sirolimus-eluting stents were more cost-effective in patients with diabetes and in those over 75 years of age, the costs per QALY gained being $44 135 and $40 129, respectively. The results were sensitive to plausible variations in the cost of stents, the estimate of the effectiveness of sirolimus-eluting stents and the assumption that sirolimus-eluting stents would prevent the need for cardiac catheterizations in the subsequent year when no revascularization procedure was performed to treat restenosis.
The use of sirolimus-eluting stents is associated with a cost per QALY that is similar to or higher than that of other accepted medical forms of therapy and is associated with a significant incremental cost. Sirolimus-eluting stents are more economically attractive for patients who are at higher risk of restenosis or at a high risk of death if a second revascularization procedure were to be required.
The prevalence of diabetes is increasing rapidly, and individuals with diabetes are at high risk for cardiovascular disorders. Subsequently the percentage of patients with diabetes subjected to revascularisation, i.e. either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) also rises rapidly. The outcome of patients with diabetes after PCI is worse than for patients without diabetes. Restenosis is the main limiting factor of the long-term success of PCI. Although stents and antithrombotics improved outcome after PCI in both diabetics and non-diabetics, diabetics still have a worse prognosis. This leads to the suggestion that the restenosis mechanism in diabetics might be different from that in non-diabetics.
Several glucose lowering agents have been shown to influence the restenosis process and thus the outcome after PCI. Current data of especially metformin and thiazolidinediones indicate beneficial results as compared to insulin and sulfonylurea on restenosis. However, no large trials have been undertaken in which the effect of glucose lowering agents on restenosis is associated with improved outcome.
The purpose of this review is to summarize the effect of diabetes and glucose lowering agents on restenosis.
There are over 1.3 million known diabetic patients in the UK and a similar number who have the disease undiagnosed. Over 90% have non-insulin dependent diabetes mellitus usually characterised by insulin resistance and adult onset. Over half of all diabetic patients die of coronary disease and account for over a fifth of percutaneous coronary intervention (PCI) revascularisation procedures. Despite recent therapeutic advances such as new antiplatelet treatments and drug eluting stents, outcomes for diabetic patients after PCI are still significantly worse than for non-diabetic patients. This article summarises what is known about the pattern and severity of diabetic coronary disease, what mechanisms are responsible for these differences, and whether this information can help explain the poorer prognosis for these patients after PCI and form the basis of interventions to improve outcome.
coronary artery disease; diabetes mellitus; inflammation; insulin resistance; percutaneous coronary intervention
Identifying the risk for restenosis is of critical importance in the stent selection process of patients undergoing percutaneous coronary intervention (PCI). Therefore, we sought to determine if a history of clinical recurrence (CR) after PCI increases the risk of CR after treatment of a de novo lesion in another coronary artery.
We retrospectively analysed all 12,763 patients who underwent PCI between 1993 and 2004 and selected patients with two or more interventions in two different native vessels. These patients were divided into two groups: patients without CR, and patients with CR after the first PCI. Clinical recurrence was defined as revascular-isation of the target vessel by either PCI or CABG within one year.
A total of 1010 patients with two or more interventions in two different native vessels were identified: 727 patients without and 283 patients with CR after the first PCI. Baseline patient characteristics and conventional risk factors were comparable between the two groups. Patients with a history of CR had a higher risk of CR after a second intervention in a second vessel (OR=3.4, 95% CI=2.3 to 4.9). A total of 112 patients also had a third intervention in a third native vessel: 12 patients with two CR, 30 patients with one CR and 70 patients with no CR after the first two interventions. CR rates in these patients were 50, 17 and 3%, respectively (p<0.001).
Patients with a history of CR have a markedly increased risk of developing CR after a second or third PCI in a different coronary artery. Therefore, in the decision-making process on whether to use a bare metal stent or drug-eluting stent, the history of CR is a simple and powerful aid. (Neth Heart J 2008;16:376-81.)
angioplasty; coronary artery disease; restenosis; percutaneous coronary intervention; drug-eluting stents
For all the wealth of research comparing the efficacy of the different types of the drug-eluting stent (DES) such as sirolimus-, paclitaxel-, and zotarolimus-eluting stents, there is still a dearth of data on the different brands of each DES type. We aimed to investigate the one-year clinical outcomes, including major adverse cardiac events (MACE), of the use of the ultra long Apollo paclitaxel-eluting stent in patients with long atherosclerotic coronary artery lesions.
According to a retrospective review of the Tehran Heart Center Registry of Interventional Cardiology, a single-center nonrandomized computerized data registry in which all adult patients who undergo single or multi-vessel percutaneous coronary intervention (PCI) are enrolled without any specific exclusion criteria, the mixed use of long Apollo paclitaxel-eluting stents and other types of the DES as well as myocardial infarction within forty-eight hours prior to the procedure was excluded. In total, 122 patients were enrolled in the study, and their baseline clinical, angiographic, and procedural characteristics were obtained. In addition, the patients’ follow-up data and, most importantly, MACE during a one-year period after intervention were recorded.
The mean follow-up duration was 14.1 ± 3.8 months. The one-year clinical follow-up data were obtained in 95.9 % of all the patients. The incidence of MACE was 5.7% during the entire study period. There was 1 death, which occurred during the initial days after PCI. The incidence of non-fatal myocardial infarction was 2.5% (3 cases), including one patient who underwent target vessel revascularization seven months later. Also, 3 patients with single-vessel disease and in-stent restenosis underwent coronary artery bypass grafting between five to ten months later.
Our results showed that the Apollo paclitaxel-eluting stent might be regarded as a safe and effective treatment for long coronary lesions.
Angioplasty; Drug-eluting stents; Coronary artery disease; Treatment outcome
Over the last three decades, percutaneous coronary intervention (PCI) technology has revolutionized the field of cardiology. PCI began in the form of balloon angioplasty, and was followed by coronary stenting. In-Stent restenosis is the main limitation of coronary stenting, and has been delayed to some extent by the development of drug eluting stents. Coronary angioplasty with stenting is currently the most popular non-medical treatment of coronary artery disease therefore solving the problem of in-stent restenosis could change the future role of other types of coronary intervention. This review examines the types of percutaneous coronary interventions, the mechanisms leading up to in-stent restenosis, and how previous and current treatments of in-stent restenosis influence the vascular response to injury.