Coronary Revascularization: New Evidence, New Challenges

Between 1970 and 2000, life expectancy in the United States increased by 6.0 years (1). Nearly two thirds of this increase (3.9 years) is credited to reductions in mortality from cardiovascular disease and stroke, and approximately 7% of the cardiovascular survival benefit has been attributed to coronary revascularization (2). After the introduction of coronary artery bypass grafting (CABG) in the 1970s, trials of revascularization from the United States and Europe demonstrated improved survival with this technique in selected subgroups of high-risk patients (such as those with left main coronary artery disease) compared with medical therapy of that era (3, 4). However, the morbidity and mortality associated with CABG encouraged development of percutaneous coronary intervention (PCI) in the 1980s. Techniques of PCI have evolved to include coronary artery stenting with bare-metal stents and, more recently, drug-eluting stents. The use of PCI to treat multivessel CAD rather than only single-vessel disease led to several randomized, controlled trials (RCTs) comparing PCI and CABG (5–8).

In this issue, Bravata and colleagues (9) present a sophisticated meta-analysis of 23 RCTs that compare health outcomes after PCI and CABG. They also compare their findings with data from selected large observational studies.

The major results of this rigorous review are that early procedural mortality rates (1.15% vs. 1.8%) and 5-year survival rates (89.7% vs. 90.7%) are similar after PCI and CABG. In addition, 5-year survival was similar after PCI and CABG in patients with and those without diabetes in the 7 RCTs that reported on this subgroup. Compared with PCI, CABG provided more complete relief of angina in 5% to 10% of patients over 5 years, and repeated revascularization was less …