Long-term safety and efficacy of percutaneous coronary intervention with stenting and coronary artery bypass surgery for multivessel coronary artery disease: a meta-analysis with 5-year patient-level data from the ARTS, ERACI-II, MASS-II, and SoS trials

Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.

Coronary artery revascularization evaluation--a multicenter registry with seven years of follow-up

Background

Data from randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) may not accurately reflect current clinical practice, in which there is off‐label usage of drug‐eluting stents (DES). We undertook a prospective registry of coronary revascularization by CABG on‐ and off‐pump and PCI with bare‐metal stents (BMSs), DESs, or percutaneous transluminal coronary angioplasty (PTCA) to determine clinical outcomes.

Methods and Results

All patients undergoing isolated coronary revascularization in 8 community‐based hospitals were enrolled. Final follow‐up was obtained after 5 years by patient and/or physician contact and the Social Security Death Index. ST‐elevation myocardial infarction and salvage patients were excluded. Five or more years of follow‐up was obtained on 81.5% (3156) of the eligible patients—968 CABG patients (82.0%) and 2188 PCI patients (81.3%). Overall follow‐up was 63.5±27.9 months (median, 79.7 months). The incidence of initial major adverse cardiac events (MACEs) at follow‐up for CABG versus PCI was 29.2% versus 41.8% (P<0.001). Analysis of stent subgroups showed more events with BMSs (equivalent to PTCA alone) compared with DESs. All stents had more events than on‐ or off‐pump CABG groups. Using propensity score–matched groups, the odds ratio for CABG to PCI was 0.69 (95% confidence interval [CI], 0.56 to 0.85; P<0.001) for mortality and 0.58 (95% CI, 0.45 to 0.75; P<0.001) for any MACE.

Conclusions

In the current era of DES and off‐pump surgery, in a community hospital setting, comparable patients undergoing coronary revascularization appear to benefit from improved long‐term survival and reduced MACE with CABG versus PCI.

Long-term survival and repeat coronary revascularization in dialysis patients after surgical and percutaneous coronary revascularization with drug-eluting and bare metal stents in the United States

BACKGROUND

Few published data describe long-term survival of dialysis patients undergoing surgical versus percutaneous coronary revascularization in the era of drug-eluting stents (DES).

METHODS AND RESULTS

Using United States Renal Data System data, we identified 23 033 dialysis patients who underwent coronary revascularization (6178 coronary artery bypass grafting, 5011 bare metal stents, 11 844 DES) from 2004 to 2009. Revascularization procedures decreased from 4347 in 2004 to 3344 in 2009. DES use decreased by 41% and bare metal stent use increased by 85% from 2006 to 2007. Long-term survival was estimated by the Kaplan-Meier method, and independent predictors of mortality were examined in a comorbidity-adjusted Cox model. In-hospital mortality for coronary artery bypass grafting patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28%, respectively. In-hospital mortality for DES patients was 2.7%; 1-, 2-, and 5-year survival was 71%, 53%, and 24%, respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes mellitus. Survival was significantly higher for coronary artery bypass grafting patients who received internal mammary grafts (hazard ratio, 0.83; P<0.0001). The probability of repeat revascularization accounting for the competing risk of death was 18% with bare metal stents, 19% with DES, and 6% with coronary artery bypass grafting at 1 year.

CONCLUSIONS

Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after coronary artery bypass grafting, but long-term survival was superior with internal mammary grafts. In-hospital mortality was lower for DES patients, but the probability of repeat revascularization was higher and comparable to that in patients receiving a bare metal stent. Revascularization decisions for dialysis patients should be individualized.

Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial

BACKGROUND

Studies from the balloon angioplasty and bare metal stent eras have demonstrated that coronary artery bypass grafting (CABG) is cost-effective compared with percutaneous coronary intervention (PCI) for patients undergoing multivessel coronary revascularization-particularly among patients with complex coronary artery disease or diabetes mellitus. Whether these results apply in the drug-eluting stent (DES) era is unknown.

METHODS AND RESULTS

Between 2005 and 2010, 1900 patients with diabetes mellitus and multivessel coronary artery disease were randomized to PCI with DES (DES-PCI; n=953) or CABG (n=947). Costs were assessed from the perspective of the U.S. health care system. Health state utilities were assessed using the EuroQOL 5 dimension 3 level questionnaire. A patient-level microsimulation model based on U.S. life-tables and in-trial results was used to estimate lifetime cost-effectiveness. Although initial procedural costs were lower for CABG, total costs for the index hospitalization were $8622 higher per patient. Over the next 5 years, follow-up costs were higher with PCI, owing to more frequent repeat revascularization and higher outpatient medication costs. Nonetheless, cumulative 5-year costs remained $3641 higher per patient with CABG. Although there were only modest gains in survival with CABG during the trial period, when the in-trial results were extended to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with substantial gains in both life expectancy and quality-adjusted life expectancy and incremental cost-effectiveness ratios <$10 000 per life-year or quality-adjusted life-year gained across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs.

CONCLUSIONS

Despite higher initial costs, CABG is a highly cost-effective revascularization strategy compared with DES-PCI for patients with diabetes mellitus and multivessel coronary artery disease.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinical-trials.gov. Unique identifier: NCT00086450.

Improving long term outcome for diabetic patients undergoing surgical revascularization by use of the radial artery conduit: a propensity matched study

Background

Diabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA.

Methods

A propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010.

Results

We compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/− SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122].

Conclusion

For diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined.

Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial

OBJECTIVES

This prespecified subgroup analysis examined the effect of diabetes on left main coronary disease (LM) and/or three-vessel disease (3VD) in patients treated with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the SYNTAX trial.

METHODS

Patients (n = 1800) with LM and/or 3VD were randomized to receive either PCI with TAXUS Express paclitaxel-eluting stents or CABG. Five-year outcomes in subgroups with (n = 452) or without (n = 1348) diabetes were examined: major adverse cardiac or cerebrovascular events (MACCE), the composite safety end-point of all-cause death/stroke/myocardial infarction (MI) and individual MACCE components death, stroke, MI and repeat revascularization. Event rates were estimated with Kaplan-Meier analyses.

RESULTS

In diabetic patients, 5-year rates were significantly higher for PCI vs CABG for MACCE (PCI: 46.5% vs CABG: 29.0%; P < 0.001) and repeat revascularization (PCI: 35.3% vs CABG: 14.6%; P < 0.001). There was no difference in the composite of all-cause death/stroke/MI (PCI: 23.9% vs CABG: 19.1%; P = 0.26) or individual components all-cause death (PCI: 19.5% vs CABG: 12.9%; P = 0.065), stroke (PCI: 3.0% vs CABG: 4.7%; P = 0.34) or MI (PCI: 9.0% vs CABG: 5.4%; P = 0.20). In non-diabetic patients, rates with PCI were also higher for MACCE (PCI: 34.1% vs CABG: 26.3%; P = 0.002) and repeat revascularization (PCI: 22.8% vs CABG: 13.4%; P < 0.001), but not for the composite end-point of all-cause death/stroke/MI (PCI: 19.8% vs CABG: 15.9%; P = 0.069). There were no differences in all-cause death (PCI: 12.0% vs CABG: 10.9%; P = 0.48) or stroke (PCI: 2.2% vs CABG: 3.5%; P = 0.15), but rates of MI (PCI: 9.9% vs CABG: 3.4%; P < 0.001) were significantly increased in the PCI arm in non-diabetic patients.

CONCLUSIONS

In both diabetic and non-diabetic patients, PCI resulted in higher rates of MACCE and repeat revascularization at 5 years. Although PCI is a potential treatment option in patients with less-complex lesions, CABG should be the revascularization option of choice for patients with more-complex anatomic disease, especially with concurrent diabetes.

Drug-eluting stents in multivessel coronary artery disease: cost effectiveness and clinical outcomes

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.

Comparison of frequency of postoperative stroke in off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting versus percutaneous coronary intervention

The stroke rate after coronary artery bypass grafting (CABG) compared to percutaneous coronary intervention (PCI) is generally considered high because cardiopulmonary bypass and aortic manipulations are often associated with cerebrovascular complications. However, an increasing number of CABGs performed without cardiopulmonary bypass (OPCAB) may improve those outcomes. Of 6,323 patients with multivessel and/or left main coronary artery disease, 3,877 patients underwent PCI, 1,381 conventional on-pump CABG, and 1,065 OPCAB. Median follow-up was 3.4 years. Stroke types were classified as early (onset of stroke within 24 hours after revascularization), delayed (within 30 days), and late (after 30 days). Propensity score analysis showed that the incidences of early, delayed, and late stroke did not differ between PCI and OPCAB (0.65, 95% confidence interval 0.08 to 5.45, p = 1.00; 0.36, 0.10 to 1.29, p = 0.23; 0.81, 0.52 to 1.27, p = 0.72, respectively). In contrast, incidence of early stroke after on-pump CABG was higher than after OPCAB (7.22, 1.67 to 31.3, p = 0.01), but incidences of delayed and late stroke were not different (1.66, 0.70 to 3.91, p = 0.50; 1.18, 0.83 to 1.69, p = 0.73). In conclusion, occurrence of stroke was not found to differ in patients after PCI versus OPCAB regardless of onset of stroke. Occurrence of early stroke after OPCAB was lower than that after on-pump CABG, yet occurrences of delayed and late strokes were similar for the 3 revascularization strategies.

Clinical outcomes after hybrid coronary revascularization versus off-pump coronary artery bypass: a prospective evaluation

OBJECTIVE

: Hybrid coronary revascularization is offered as an alternative strategy for patients with multivessel coronary artery disease (CAD). We present our experience and provide a comparative analysis to off-pump coronary artery bypass grafting (OPCAB).

METHODS

: Ninety-one patients with multivessel CAD underwent minimally invasive left internal mammary artery to left anterior descending grafting in combination with percutaneous coronary intervention of nonleft anterior descending targets (HYBRID). The primary end point of this study was major adverse cardiac and cerebrovascular events (MACCE), defined as death, stroke, and nonfatal myocardial infarction. MACCE in the HYBRID group were compared with 4175 contemporaneously performed OPCAB operations by logistic (30-day outcomes) and Cox proportional hazards (long-term survival) regression methods. Propensity scoring was used to adjust for potential selection bias.

RESULTS

: The 30-day MACCE (death/stroke/nonfatal myocardial infarction) rate was 1.1% for the HYBRID group (0%/0%/1.1%) and 3.0% for the OPCAB group (1.8%/1.1%/0.5%) (odds ratio = 0.47, P = 0.48). Angiographic left internal mammary artery evaluation was obtained in 95.6% of patients (87 of 91) revealing FitzGibbon A patency in 98.0% (96 of 98). The reintervention rate at 1 year for the HYBRID group was 5.5% (5 of 91) and was limited to repeat percutaneous coronary intervention. Three-year survival was statistically similar for the two groups (hazard ratio = 0.44, P = 0.18, see Kaplan-Meier figure).

CONCLUSIONS

: Hybrid coronary revascularization may be noninferior to OPCAB with respect to early MACCE and 3-year survival in the treatment of multivessel CAD.

Outcomes of coronary revascularization (percutaneous or bypass) in patients with diabetes mellitus and multivessel coronary disease

Clinical outcomes in patients with diabetes mellitus and multivessel disease (MVD) undergoing coronary revascularization have not been extensively evaluated, we sought to examine outcomes in a diabetic cohort of 195 consecutive patients with MVD characterized by SYNTAX scores (SSs) undergoing nonrandomized revascularization, 102 (52%) by percutaneous intervention (PCI) and 93 (48%) by coronary artery bypass grafting (CABG) at Liverpool Hospital (Sydney, Australia) from June 2006 to March 2010. Clinical outcomes were assessed at a median term of 14 months. The overall median SS was 44, with significantly higher SSs in CABG- than PCI-treated patients (48 vs 39, p <0.0001). There was a similar incidence of all-cause death, nonfatal myocardial infarction and stroke in PCI- and CABG-treated patients (6.1% vs 8.3%, p = 0.383; 12% vs 4.9%, p = 0.152; 3.1% vs 3.5%, p = 0.680 respectively). However, the rates of target vessel revascularization and major adverse coronary and cerebral event were significantly higher in PCI-treated patients than in those undergoing CABG (20% vs 1.2%, p <0.0001; 29% vs 15%, p = 0.034). Despite a much higher SS, patients who underwent PCI achieved comparable outcomes at 1 year to those with diabetes mellitus and a SS ≥ 33 as reported in the SYNTAX trial. In conclusion, in this single-center nonrandomized observational study, coronary revascularization by PCI is associated with increased major adverse coronary and cerebral events at 1-year follow-up, predominantly driven by a high rate of target vessel revascularization. Thus, CABG should remain the revascularization procedure of choice for diabetic patients with MVD and high SSs.

Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention

OBJECTIVES

This study sought to determine whether coronary artery bypass graft (CABG) surgery is associated with an increased risk of stroke compared with percutaneous coronary intervention (PCI).

BACKGROUND

Some, but not all, randomized trials have reported increased rates of stroke with CABG compared with PCI. However, all these studies were powered insufficiently to examine differences in the risk of stroke reliably.

METHODS

We performed a meta-analysis of 19 trials in which 10,944 patients were randomized to CABG versus PCI. The primary end point was the 30-day rate of stroke. We also determined the rate of stroke at the midterm follow-up and investigated whether there was an interaction between revascularization type and the extent of coronary artery disease on the relative risk of stroke.

RESULTS

The 30-day rate of stroke was 1.20% after CABG compared with 0.34% after PCI (odds ratio: 2.94, 95% confidence interval: 1.69 to 5.09, p < 0.0001). Similar results were observed after a median follow-up of 12.1 months (1.83% vs. 0.99%, odds ratio: 1.67, 95% confidence interval: 1.09 to 2.56, p = 0.02). The extent of coronary artery disease (single vessel vs. multivessel vs. left main) did not affect the relative increase in the risk of stroke observed with CABG compared with PCI at either 30 days (p = 0.57 for interaction) or midterm follow-up (p = 0.08 for interaction). Similar results were observed when the outcomes in 33,980 patients from 27 observational studies were analyzed.

CONCLUSIONS

Coronary revascularization by CABG compared with PCI is associated with an increased risk of stroke at 30 days and at the mid-term follow-up.

Changes in the safety paradigm with percutaneous coronary interventions in the modern era: Lessons learned from the ASCERT registry

In the past, comparative effectiveness trials evaluating percutaneous coronary interventions (PCI), using either balloon angioplasty or bare metal stent (BMS) implantation, versus coronary artery bypass surgery (CABG) found similar survival rates at long-term follow-up with both revascularization strategies. Two major meta-analyses of these trials reported 5- and 6-year comparative effectiveness between PCI and CABG: one included only four trials that compared PCI with BMS implantation versus CABG whereas the largest one also included trials using balloon angioplasty. In these studies, the authors observed no survival differences between groups although a significant survival advantage was seen in diabetics treated with CABG and this benefit was also perceived in elderly patients. In both reports, number of involved vessels, presence of left anterior descending artery stenosis or poor left ventricular ejection fraction were no predictors of poor survival with PCI. Therefore, extent of the coronary artery disease (CAD) was not associated with poor outcome after PCI in the pre-drug eluting stent (DES) era. Recently, the ASCERT (Database Collaboration on the Comparative Effectiveness of Revascularization Strategies) registry found higher mortality rate with PCI in patients ≥ 65 years old in comparison with CABG, and advantages of surgery were seen in all subgroups including those at low risk. In this registry, PCI was accomplished by implantation of the first type of DES designs in 78% of cases. The intriguing observation of high mortality rate with PCI, including for non-diabetics and patients with two-vessel CAD, meaning a lack of clinical benefit with DES implantation, had not been seen previously. The study was not randomized, although its results are largely strengthened by its sample size. In this manuscript, the authors describe other registries and randomized trials reporting similar results supporting the findings of the aforementioned study and explore the reasons for these results, while also searching for potential solutions.

Long-term outcome of stents versus bypass surgery in diabetic and nondiabetic patients with multivessel or left main coronary artery disease: a pooled analysis of 5775 individual patient data

BACKGROUND

Coronary artery bypass grafting and percutaneous coronary intervention (PCI) are alternative treatments for complex multivessel or left main disease. However, the relative treatment effects in diabetic and nondiabetic patients remain uncertain.

METHODS AND RESULTS

We performed a pooled analysis of 5775 patients from 3 clinical studies comparing PCI and coronary artery bypass grafting for multivessel or left main disease and compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and repeat revascularization) according to the diabetic status. Over a median follow-up of 5.5 years, risk-adjusted mortality after PCI relative to coronary artery bypass grafting was not different in diabetic (hazard ratio [HR], 1.15; 95% CI, 0.88-1.51) and nondiabetic (HR, 1.15; 95% CI, 0.88-1.50) patients. The adjusted risks of the composite outcome of death, Q-wave myocardial infarction, or stroke were also not different in diabetic (HR, 1.00; 95% CI, 0.79-1.26) and nondiabetic (HR, 0.99; 95% CI, 0.78-1.26) patients. However, PCI was significantly associated with higher risk of repeat revascularization both in diabetic (HR, 3.56; 95% CI, 2.62-4.83) and in nondiabetic (HR, 3.55; 95% CI, 2.61-4.83) patients. Significant interactions were absent between diabetic status and revascularization strategies for death (P=0.27), composite outcome of death, Q-wave myocardial infarction, or stroke (P=0.97), and repeat revascularization (P=0.08).

CONCLUSIONS

For multivessel or left main disease, the long-term risks of mortality and composite serious outcomes were not different between PCI and coronary artery bypass grafting in diabetic and nondiabetic patients, but PCI was associated with higher risk of repeat revascularization. These relative treatment effects were not modified by diabetic status. These results are hypothesis generating and should be addressed in a randomized trial.

Revascularization for left main and multivessel coronary artery disease in the drug-eluting stent era: integration of recent drug-eluting stent trials

As older patients comprise a greater proportion of the population, the incidence of multivessel and left main coronary artery disease is increasing. Given the improvements in percutaneous coronary intervention, more patients are suitable for this revascularization strategy. However, the optimal revascularization strategy remains a moving target. Numerous trials, extending from the bypass surgery versus medical therapy era to the most current drug-eluting stent versus bypass surgery era, provide information to select the most appropriate revascularization strategy. The objective of this review is to summarize these data.

Contemporary management of ST-segment elevation myocardial infarction

Coronary heart disease is the leading cause of death worldwide. In the United States, approximately 1 of every 6 deaths in 2007 was caused by coronary heart disease. Clinical presentation in the acute setting is mostly due to atherosclerotic plaque rupture leading to flow limitation in the affected vessel, and myocardial ischemia and infarction. ST-segment elevation myocardial infarction is usually associated with complete occlusion of the coronary artery and carries the worst prognosis in terms of in-hospital mortality. Despite various advances in treatment options, including percutaneous coronary intervention, ischemic heart disease still carries a significant morbidity and mortality. In this article, we aim to provide a summary of a few key advances in the management of ST-segment elevation myocardial infarction.

In vivo assessment of intraplaque and endothelial fibrin in ApoE(-/-) mice by molecular MRI

OBJECTIVE

Molecular magnetic resonance imaging (MRI) has emerged as a promising non-invasive modality to characterize atherosclerotic vessel wall changes on a morphological and molecular level. Intraplaque and endothelial fibrin has recently been recognized to play an important role in the progression of atherosclerosis. This study aimed to investigate the feasibility of intraplaque and endothelial fibrin detection using a fibrin-targeted contrast-agent, FTCA (EPIX Pharmaceuticals, Lexington, MA), in a mouse model of atherosclerosis.

METHODS

Male apolipoproteinE-knockout mice (ApoE(-/-)) were fed a high fat diet (HFD) for one to three months. MRI of the brachiocephalic artery was performed prior to and 90 min after the administration of FTCA (n=8 per group). Contrast to noise ratios (CNR) and longitudinal relaxation rates (R1) of plaques were determined and compared to ex vivo fibrin density measurements on immunohistological sections stained with a fibrin-specific antibody and gadolinium concentrations measured by inductively coupled mass spectroscopy (ICP-MS).

RESULTS

Molecular MRI after FTCA administration demonstrated a significant increase (p<0.05) in contrast agent uptake in brachiocephalic artery plaques. In vivo CNR measurements were in good agreement with ex vivo fibrin density measurements on immunohistochemistry (y=2.4x+11.3, R(2)=0.82) and ICP-MS (y=0.95x+7.1, R(2)=0.70). Late stage atherosclerotic plaques displayed the strongest increase in CNR, R1, ex vivo fibrin staining and gadolinium concentration (p<0.05).

CONCLUSION

This study demonstrated the feasibility of intraplaque and endothelial fibrin imaging using FTCA. Direct in vivo fibrin detection and quantification could be useful for characterization and staging of coronary and carotid atherosclerotic lesions, which may aid diagnosis and intervention.

Significance of off-pump coronary artery bypass grafting compared with percutaneous coronary intervention: a propensity score analysis

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

[Modern coronary surgery, the SYNTAX trial and updated guidelines]

Coronary artery bypass grafting (CABG), a modern and safe procedure, is considered the therapy of choice in the care of patients with multi-vessel disease. The 3-year results of the SYNTAX trial not only showed surgical advantages in terms of repeat revascularisation, but the results also demonstrated significant surgical benefit for myocardial infarction and survival rates. More differentiated analyses showed distinct disadvantages in percutaneous coronary intervention (PCI) associated with the greater complexity of coronary pathology. PCI tends to be a comparable therapeutic option only in certain cases of left main stem lesions or multi-vessel disease. The findings from the SYNTAX study herald a new era in the treatment of coronary heart disease in which, as recommended in the updated guidelines issued by the EACTS/ESC in 2010, the interventionalist and the surgeon, working closely together as a"heart team", provide a sound therapy plan for affected patients.

Long-term mortality of coronary artery bypass grafting and bare-metal stenting

BACKGROUND

There is little information on relative survival with follow-up longer than 5 years in patients undergoing coronary artery bypass grafting (CABG) and patients undergoing percutaneous coronary intervention (PCI) with stenting. This study tested the hypothesis that CABG is associated with a lower risk of long-term (8-year) mortality than is stenting with bare-metal stents for multivessel coronary disease.

METHODS

We identified 18,359 patients with multivessel disease who underwent isolated CABG and 13,377 patients who received bare-metal stenting in 1999 to 2000 in New York and followed their vital status through 2007 using the National Death Index (NDI). We matched CABG and stent patients on the number of diseased coronary vessels, proximal left anterior descending (LAD) artery disease, and propensity of undergoing CABG based on numerous patient characteristics and compared survival after the 2 procedures.

RESULTS

In the 7,235 pairs of matched patients, the overall 8-year survival rates were 78.0% for CABG and 71.2% for stenting (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.64 to 0.74; p < 0.001). For anatomic groups classified by the number of diseased vessels and proximal LAD involvement, the HRs ranged from 0.53 (p < 0.001) for patients with 3-vessel disease involving proximal LAD artery disease to 0.78 (p = 0.05) for patients with 2-vessel disease but no disease in the LAD artery. A lower risk of death after CABG was observed in all subgroups stratified by a number of baseline risk factors.

CONCLUSIONS

Coronary artery bypass grafting is associated with a lower risk of death than is stenting with bare metal stents for multivessel coronary disease.

Economic outcomes of percutaneous coronary intervention with drug-eluting stents versus bypass surgery for patients with left main or three-vessel coronary artery disease: one-year results from the SYNTAX trial

OBJECTIVES

To evaluate the cost-effectiveness of alternative approaches to revascularization for patients with three-vessel or left main coronary artery disease (CAD).

BACKGROUND

Previous studies have demonstrated that, despite higher initial costs, long-term costs with bypass surgery (CABG) in multivessel CAD are similar to those for percutaneous coronary intervention (PCI). The impact of drug-eluting stents (DES) on these results is unknown.

METHODS

The SYNTAX trial randomized 1,800 patients with left main or three-vessel CAD to either CABG (n = 897) or PCI using paclitaxel-eluting stents (n = 903). Resource utilization data were collected prospectively for all patients, and cumulative 1-year costs were assessed from the perspective of the U.S. healthcare system.

RESULTS

Total costs for the initial hospitalization were $5,693/patient higher with CABG, whereas follow-up costs were $2,282/patient higher with PCI due mainly to more frequent revascularization procedures and higher outpatient medication costs. Total 1-year costs were thus $3,590/patient higher with CABG, while quality-adjusted life expectancy was slightly higher with PCI. Although PCI was an economically dominant strategy for the overall population, cost-effectiveness varied considerably according to angiographic complexity. For patients with high angiographic complexity (SYNTAX score > 32), total 1-year costs were similar for CABG and PCI, and the incremental cost-effectiveness ratio for CABG was $43,486 per quality-adjusted life-year gained.

CONCLUSIONS

Among patients with three-vessel or left main CAD, PCI is an economically attractive strategy over the first year for patients with low and moderate angiographic complexity, while CABG is favored among patients with high angiographic complexity.

Impact of repeated percutaneous coronary intervention on long-term survival after subsequent coronary artery bypass surgery

(Background)

In the current stent era, aggressive repeated percutaneous coronary intervention (PCI) has become more common. The aim of this study was to investigate the impact of previous repeated PCI on the subsequent coronary artery bypass grafting (CABG).

(Methods)

Between January 1990 and January 2008, a total of 894 patients underwent first-time isolated elective CABG. Among the 894 patients, 515 patients had had no PCI (group A), 179 patients had had single PCI (Group B), and 200 patients had had multiple PCI (2-15 times, mean 3.6 ± 2.3 times) (group C) before CABG. These groups were compared in terms of early and late clinical results.

(Results)

Preoperative left ventricular ejection fraction was significantly higher in group A (group A;58 ± 13%, group B;54 ± 12%, and group C;54 ± 12%). Number of bypass grafts was significantly smaller in group C (A:3.3 ± 1.0, B 3.4 ± 0.9, C 3.1 ± 1.0). Although there was no statistically significant difference among the groups, in-hospital mortality in group C was higher than that in group A and B (A:1.6%, B:1.1%, C:3.5%, p = 0.16). Survival analysis by Kaplan-Meier method (mean follow-up: 58 ± 43 methods) revealed that freedom from all-cause death and cardiac death was significantly lower in group C in comparison with group A. Freedom from cardiac event was significantly higher in group C than that in group A. Multivariate analysis identified a number of previous PCI as an independent risk factor for cardiac death.

(Conclusions)

Repeated PCI increased risk for long-term prognosis of subsequent CABG.

Percutaneous coronary intervention vs coronary artery bypass grafting in the management of chronic stable angina: A critical appraisal

Chronic stable angina is a clinical expression of myocardial ischemia associated with fixed atherosclerotic coronary stenosis, which prevents the adaptation of coronary circulation resulting in an increased oxygen requirement. We recommend that once the diagnosis of chronic stable angina is made, first every patient should be offered the optimal medical therapy, including ACE inhibitors, beta-blockers, statins, and nitrates. If the patients' symptoms are not controlled in spite of these drugs being used in maximum tolerated dosages, then these patients should be subjected to coronary angiography. If a patient shows a single-or double-vessel disease, then PCI should be offered. On the contrary, if the coronary angiogram shows a triple-vessel disease and left main disease, then one has to look for comorbidities that put the patient at a higher risk of CABG and the patient should be treated with PCI. Other patients with left main and triple-vessel disease having diabetes and left ventricular dysfunction should go directly for surgical revascularization. Overall, health related quality of life (HRQoL) is similar in both PCI and CABG.

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.

Stenting of complex lesions: an overview

Contemporary management of coronary artery disease relies increasingly on percutaneous techniques combined with medical therapy. Although percutaneous coronary intervention (PCI) can be performed successfully in most lesions, several difficult lesion subsets continue to present unique technical challenges. These complex lesions may be classified according to anatomic criteria, including extensive calcification, thrombus, and chronic occlusions, or by location, such as bifurcations, saphenous vein grafts and unprotected left main. PCI of these lesions often requires novel devices, such as drug-eluting stents, hydrophilic guidewires, distal protection balloons or filters, thrombectomy catheters, rotational atherectomy, and cutting balloons. An integrated approach that combines these devices with specialized techniques and adjunctive pharmacologic agents has greatly improved PCI success rates for these complex lesions.

[3-year results of the SYNTAX trial--stent or surgery? A surgeon's perspective]

Coronary artery bypass grafting (CABG) is the standard of care for patients with three-vessel or left main coronary artery disease. However, clinical practice has proven to differ substantially with even the most complex coronary lesions being targeted by percutaneous coronary intervention (PCI) today. An abundancy of both large registries and randomized clinical trials has demonstrated superiority of surgery over PCI in advanced coronary artery disease. Recently, these results have been confirmed by the landmark SYNTAX trial where CABG was found to be superior to PCI for three-vessel and/or left main coronary artery disease regarding repeat revascularization, rate of myocardial infarction, and cardiac mortality at the latest follow-up of 3 years. On the other hand, PCI proved to be a viable alternative for less complex forms of left main disease.In conclusion, patients with three-vessel and/or left main coronary artery disease should be discussed in an interdisciplinary heart team consisting of cardiologists and cardiac surgeons within a heart center. Final decision making should be a formal process as recommended in the recently updated guidelines on myocardial revascularization by the European Society of Cardiology.

Risk-benefit trade-offs in revascularisation choices

AIMS

When patients choose percutaneous coronary intervention (PCI) over coronary artery bypass grafting (CABG), they accept an increased long-term risk of repeat revascularisation in exchange for short-term morbidity benefits. This paper quantifies the risk-benefit trade-off faced by patients with multiple vessel coronary artery disease.

METHODS AND RESULTS

Data from the Arterial Revascularisation Therapies Study are used to generate risk-benefit acceptability curves for PCI versus CABG. Risks are measured by the long-term likelihood of repeat revascularisation while benefits are measured by short-term reductions in pain or improvements in health-related quality of life (HRQL). PCI patients faced a risk of 0.81 additional revascularisation events over three years in exchange for being pain-free at one month. A patient would need to be willing to tolerate a risk of 1.06 additional revascularisation events at three years, in exchange for being pain free at one month to be 95% confident that choosing PCI over CABG is risk-effective for him/her.

CONCLUSIONS

The risk-benefit framework outlined in this study provides information to enable physicians to help their patients weigh directly each procedure's risks and benefits. While trade-offs are typically measured in quality-adjusted life years, using pain reduction to reflect benefits may provide a more tangible framework for patients.

Complex coronary anatomy in coronary artery bypass graft surgery: impact of complex coronary anatomy in modern bypass surgery? Lessons learned from the SYNTAX trial after two years

OBJECTIVE

SYNTAX study compares outcomes of coronary artery bypass grafting with percutaneous coronary intervention in patients with 3-vessel and/or left main disease. Complexity of coronary artery disease was quantified by the SYNTAX score, which combines anatomic characteristics of each significant lesion. This study aims to clarify whether SYNTAX score affects the outcome of bypass grafting as defined by major adverse cerebrovascular and cardiac events (MACCE) and its components over a 2-year follow-up period.

METHODS

Of the 3075 patients enrolled in SYNTAX, 1541 underwent coronary artery bypass grafting (897 randomized controlled trial patients, and 644 registry patients). All patients undergoing bypass grafting were stratified according to their SYNTAX score into 3 tertiles: low (0-22), intermediate (22-32), and high (≥33) complexity. Clinical outcomes up to 2 years after allocation were determined for each group and further risk factor analysis was performed.

RESULTS

Registry patients had more complex disease than those in the randomized controlled trial (SYNTAX score: registry 37.8 ± 13.3 vs randomized 29.1 ± 11.4; P < .001). At 30 days, overall coronary bypass mortality was 0.9% (registry 0.6% vs randomized 1.2%). MACCE rate at 30 days was 4.4% (registry 3.4% vs randomized 5.2%). SYNTAX score did not significantly affect overall 2-year MACCE rate of 15.6% for low, 14.3% for medium, and 15.4% for high SYNTAX scores. Compared with randomized patients, registry patients had a lower rate of overall MACCE rate (registry 13.0% vs randomized 16.7%; P = .046) and repeat revascularization (4.7% vs 8.6%; P = .003), whereas other event rates were comparable. Risk factor analysis revealed left main disease (P = .049) and incomplete revascularization (P = .005) as predictive for adverse 2-year outcomes.

CONCLUSIONS

The outcome of coronary artery bypass grafting was excellent and independent from the SYNTAX score. Incomplete revascularization rather than degree of coronary complexity adversely affects late outcomes of coronary bypass.

Propensity score analysis of 10-year long-term outcome after bypass surgery or plain old balloon angioplasty in patients with metabolic syndrome

Clinical hard outcomes (death and myocardial infarction) between bypass surgery (CABG) and percutaneous coronary intervention (PCI) are generally similar, whereas target vessel revascularization and angina relief are often superior with CABG. However, there are no data regarding 10-year long-term clinical outcomes between the two procedures in metabolic syndrome (MetS). The aim of this study was to assess the long-term outcomes of CABG and plain old balloon angioplasty (POBA) in MetS patients. We enrolled 869 patients, 318 (36.6%) and 551 (63.4%) of whom underwent POBA and CABG, respectively. During follow-up (10.1 ± 3.5 years), 221 patients died (118 cardiovascular deaths) and 256 underwent revascularization. We predicted the probability of undergoing CABG using propensity analysis. Unadjusted survival was significantly lower in the CABG group because of unfavorable baseline characteristics. After adjusting for baseline variables including propensity score, POBA and CABG did not differ in terms of all cause (hazard ratio [HR] of CABG, 1.46; P = 0.132) and cardiovascular mortality (HR of CABG, 1.11; P = 0.757). However, the risk of subsequent revascularization was significantly lower in the CABG group than in the POBA group (HR of CABG, 0.15; P < 0.001). This study demonstrated that CABG is superior to POBA in terms of target vessel revascularization in MetS patients, whereas there were no significant differences in mortality after adjusting for baseline variables including propensity score.

Coronary revascularisation in chronic kidney disease. Part 1: stable coronary artery disease

Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease, myocardial infarction and cardiovascular death. Detection and treatment of coronary artery disease in CKD patients has been hampered by the limitations of screening tests, the lack of direct evidence for therapeutic interventions in this specific population, and concerns about therapy-related adverse effects. However, these patients potentially have much to gain from conventional strategies used in the general population. This review summarises the current evidence regarding the treatment of coronary artery disease in patients with CKD, with the focus on coronary revascularisation by percutaneous coronary intervention or coronary artery bypass grafting.

Coronary artery disease: revascularization strategies for patients with CAD and diabetes

CABG surgery has been considered the optimal revascularization strategy for patients with diabetes mellitus who have lexft main and/or multivessel coronary artery disease. The results of a new analysis of data from the SYNTAX trial challenge this conventional wisdom and highlight additional coronary revascularization options to physicians and patients.

Coronary Artery Bypass Grafting After Recent or Remote Percutaneous Coronary Intervention in the Commonwealth of Massachusetts

Background—

In this study, we sought to characterize the outcomes after isolated coronary artery bypass grafting (CABG) in patients with a history of remote (≥14 days), and recent (<14 days), percutaneous coronary intervention (PCI).

Methods and Results—

Patients with PCI within 5 years of CABG were identified among 12 591 primary isolated CABG reported in the mandatory Massachusetts Adult Cardiac Surgery Database. Patients were excluded if they were out-of-state (n=1043, 8%), had undergone primary PCI for acute myocardial infarction (n=401, 3%), had a PCI-CABG interval >5 years or unknown (n=136 and n=673, 1% and 5%). Patients with a history of remote and recent PCI were analyzed separately. Each CABG patient with PCI was matched to 3 patients without PCI using a propensity score. Outcomes were analyzed using generalized estimating equations and stratified proportional hazards models, with a mean follow-up of 4.1±1.2 years. There were 1117 CABG patients (9%) with prior PCI (n remote =823; n recent =294). In matched CABG patients with remote prior PCI, no differences were found in 30-day mortality (1.1% versus 1.5%; P =0.432), hospital morbidity (41% versus 40%; P =0.385) and overall survival (hazard ratio, [95% confidence interval] for death for prior PCI, 0.93 [0.74 to 1.18]; P =0.555). In matched CABG patients with recent prior PCI, hospital morbidity was higher (59% versus 45%; P <0.001), but no differences were found in 30-day mortality (3.5% versus 3.1%; P =0.754) and overall survival (HR, 1.18 [0.83 to 1.69]; P =0.353).

Conclusions—

In patients undergoing CABG, remote prior PCI (≥14 days) was not associated with adverse outcomes at 30 days or during long-term follow-up.

One-year clinical follow-up of a registry evaluating a percutaneous revascularisation strategy combining a pre-specified simple selection process with the use of a new thin-strut bare cobalt-chromium stent

Objectives. To evaluate clinical events in a specifically selected cohort of patients with obstructive coronary artery disease (CAD), using a new generation thin-strut bare cobalt-chromium coronary stent.Methods. Patients with single- or multi-vessel, stable or unstable CAD eligible for percutaneous implantation of at least one bare cobalt-chromium stent were evaluated in a single-centre registry. Prospective pre-specified criteria for bare cobalt-chromium stent implantation in our centre were: any acute ST-elevation myocardial infarction (MI), otherwise 1) de novo coronary lesion, and 2) lesion length <20 mm, and 3) reference vessel diameter >2.6 mm, and 4) no diabetes, unless reference vessel diameter >3.5 mm. Endpoints, retrospectively collected, were death, MI and clinically driven target-lesion revascularisation (TLR) and target-vessel revascularisation (TVR) after 12 months.Results. Between September 2005 and June 2007, 712 patients (48.7% one-vessel, 29.9% two-vessel, 20% three-vessel and 1.4% left main disease; 7.9% diabetics) were treated with 800 bare cobalt-chromium stents, for stable angina (40.9%), unstable angina (20.9%) or acute ST-elevation MI (38.2%). The procedural success rate was 99.3%. Peri-procedural MI rate was 2.2% in the semi-elective group. At 12 months there were 17 deaths (2.4%), of which nine non-cardiac, 20 (2.8%) MI, 19 (2.7%) TLR and 29 (4.1%) TVR. Early and late definite stent thrombosis occurred in four (0.6%) and three (0.4%) patients, respectively.Conclusion. A strategy aimed at minimising drug-eluting stent use and combining a pre-specified simple selection process with the use of a new thin-strut bare cobalt-chromium stent is safe and effective at one-year clinical follow-up. (Neth Heart J 2010;18:486-92.).

Major predictors of long-term clinical outcomes after coronary revascularization in patients with unprotected left main coronary disease: analysis from the MAIN-COMPARE study

BACKGROUND

The clinical characteristics that identify high-risk subsets of patients with unprotected left main coronary artery disease undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have not been well established.

METHODS AND RESULTS

Between January 2000 and June 2006, 2240 patients with unprotected left main coronary artery disease underwent PCI (n=1102) or CABG (n=1138). Twenty-six preprocedural parameters were evaluated by univariate and multivariate Cox regression analysis to identify independent predictors of all-cause mortality and target-vessel revascularization. Interaction tests were performed to compare heterogeneities of effects of preprocedural parameters depending on the revascularization methods. During follow-up (median of 3.1 years), 187 patients died (78 PCI and 109 CABG) and 149 patients had target-vessel revascularization (121 PCI and 28 CABG). EuroSCORE > or =6 was an independent predictor of death in both groups. Additional independent predictors were chronic renal failure and previous congestive heart failure in the PCI group and age > or =75 years, atrial fibrillation, right coronary artery disease, and left main distal bifurcation disease in the CABG group. Interaction analysis showed no heterogeneities of the effects of variables depending on the revascularization methods. Independent predictors of target-vessel revascularization were acute coronary syndrome and left main distal bifurcation disease in the PCI group and history of coronary intervention in the CABG group. The interaction between previous PCI and treatment remained after adjustment for all independent predictors of target-vessel revascularization (interaction P=0.0345).

CONCLUSIONS

Several clinical characteristics were identified as important preprocedural predictors of long-term adverse outcomes after percutaneous or surgical revascularization in patients with unprotected left main coronary artery disease.

Ten-year follow-up survival of the Medicine, Angioplasty, or Surgery Study (MASS II): a randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease

BACKGROUND

This study compared the 10-year follow-up of percutaneous coronary intervention (PCI), coronary artery surgery (CABG), and medical treatment (MT) in patients with multivessel coronary artery disease, stable angina, and preserved ventricular function.

METHODS AND RESULTS

The primary end points were overall mortality, Q-wave myocardial infarction, or refractory angina that required revascularization. All data were analyzed according to the intention-to-treat principle. At a single institution, 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). The 10-year survival rates were 74.9% with CABG, 75.1% with PCI, and 69% with MT (P=0.089). The 10-year rates of myocardial infarction were 10.3% with CABG, 13.3% with PCI, and 20.7% with MT (P<0.010). The 10-year rates of additional revascularizations were 7.4% with CABG, 41.9% with PCI, and 39.4% with MT (P<0.001). Relative to the composite end point, Cox regression analysis showed a higher incidence of primary events in MT than in CABG (hazard ratio 2.35, 95% confidence interval 1.78 to 3.11) and in PCI than in CABG (hazard ratio 1.85, 95% confidence interval 1.39 to 2.47). Furthermore, 10-year rates of freedom from angina were 64% with CABG, 59% with PCI, and 43% with MT (P<0.001).

CONCLUSIONS

Compared with CABG, MT was associated with a significantly higher incidence of subsequent myocardial infarction, a higher rate of additional revascularization, a higher incidence of cardiac death, and consequently a 2.29-fold increased risk of combined events. PCI was associated with an increased need for further revascularization, a higher incidence of myocardial infarction, and a 1.46-fold increased risk of combined events compared with CABG. Additionally, CABG was better than MT at eliminating anginal symptoms. Clinical Trial Registration Information- URL: http://www.controlled-trials.com.

REGISTRATION NUMBER

ISRCTN66068876.