When to recommend PCI, CABG or medical therapy

The most recent guidelines published in the Journal of the American College of Cardiology by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions, say that the best outcomes may be found with a multidisciplinary team approach: a Heart Team. The Heart Team consists of an interventional cardiologist and a cardiac surgeon. According to the guidelines, the team should review the patient's medical condition and coronary anatomy together, determine whether the patient should undergo PCI or CABG based on technical feasibility, and counsel patients on revascularization options before selecting either treatment.

“Support for using a Heart Team approach comes from reports that patients with complex CAD referred specifically for PCI or CABG in concurrent trial registries have lower mortality rates than those randomly assigned to PCI or CABG in controlled trials,” the task force wrote.

In a systematic review published in a 2013 edition of The Journal of the American Medical Association, researchers examined current evidence comparing the effectiveness of CABG surgery and PCI. The patients in the study had unprotected left main disease, ULMD, multivessel CAD, diabetes or left ventricular dysfunction (LVD).

“Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences and local expertise,” the researchers wrote in the conclusion.

In another study published in the April 2014 edition of the Journal of the American College of Cardiology, Ganesh Athappan, MD, of Case Western Reserve University, Cleveland, OH, and the Cleveland Clinic, compared evidence on optimal medical therapy and revascularization treatments for stable coronary artery disease. The study concluded that the current guidelines may not reflect the improvements in CAD therapeutics made over the years.

References:

Levine GN. J Am Coll Cardiol. 2011;doi:10.1016/j.jacc.2011.08.007.

Deb S. JAMA. 2013;doi:10.1001/jama.2013.281718.

Athappan G. J Am Coll Cardiol. 2014;doi:10.1016/S0735-1097(14)61596-5.