Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Grafting for Coronary Artery Disease: Comparative Effectiv (en Inglés)
Reseña del libro "Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Grafting for Coronary Artery Disease: Comparative Effectiv (en Inglés)"
Atherosclerosis develops in a patchy, discontinuous fashion within coronary arteries. Therefore, it is possible to treat the discrete areas of obstruction that most impede coronary blood flow to the myocardium. The mechanical approaches to coronary revascularization fall broadly into two categories: coronary artery bypass grafting surgery (CABG) and catheter-based percutaneous coronary interventions (PCI). Together, these coronary revascularization methods are among the most common major medical procedures performed in North America and Europe. Coronary bypass surgery and coronary angioplasty (with or without stents) are alternative approaches to mechanical coronary revascularization, so their comparative effectiveness in terms of patient outcomes has been of great interest. The comparative effectiveness of bypass surgery and angioplasty is an open question primarily for those patients for whom either procedure would be technically feasible and whose coronary disease is neither too limited nor too extensive. CABG is generally preferred for patients with left main coronary artery disease or severe triple-vessel disease with reduced left ventricular function because it has been previously shown in randomized trials to improve survival compared with medical therapy. In contrast, PCI is generally preferred for patients with most forms of single-vessel disease when symptoms warrant coronary revascularization, in light of its lower procedural risk and the evidence that PCI reduces angina and myocardial ischemia in this subset of patients. The choice between PCI and CABG is most relevant for patients whose coronary artery disease (CAD) lies in between these extremes, namely patients with single-vessel disease of the proximal left anterior descending artery (LAD), most forms of double-vessel CAD, and less extensive forms of triple-vessel CAD. Most randomized controlled clinical trials (RCTs) of angioplasty and surgery have been conducted in this middle segment of the patient population with CAD. The purpose of this report is to evaluate the evidence for the comparative effectiveness of PCI and CABG in this population of patients with CAD. Specifically, the report addresses the following key questions: KQ 1a. In patients with ischemic heart disease and angiographically proven single or multi-vessel disease, what is the effectiveness of PCI compared with CABG in reducing the occurrence of adverse objective outcomes and improving subjective outcomes? KQ 1b. Over what period of time are the comparative benefits of PCI and CABG sustained? KQ 2. Is there evidence that the comparative effectiveness of PCI and CABG varies based on: a. Age, sex, race, or other demographic risk factors? b. Coronary disease risk factors, diabetes, or other comorbid disease? c. Angiographic-specific factors including, but not limited to, the number of diseased vessels amenable to bypass or stenting, vessel territory of stenoses (e.g., left main or anterior descending coronary arteries, right coronary artery, circumflex coronary artery), diffuse vs. focal stenoses, left ventricular function, or prior revascularization procedures? d. CABG-specific factors including, but not limited to, cardiopulmonary bypass mode (normothermic vs. hypothermic), type of cardioplegia used (blood vs. crystalloid), or use of saphenous vein grafts, single or bilateral internal mammary artery grafts, or other types of bypass grafts? e. Clinical presentation (e.g., stable angina or unstable angina based on New York Heart Association functional class I-IV, acute coronary syndrome, cardiogenic shock, acute myocardial infarction with or without ST elevation, or silent ischemia)? f. Adjunctive medical therapies, such as short-term intravenous or oral antiplatelet drugs, or long-term use of oral antiplatelet drugs? g. Process characteristics such as provider volume, hospital volume, and setting (e.g., academic vs. community)? h. Prior PCI or CABG revascularization procedures?
