Current concepts in coronary artery revascularisation

“More than five decades after the introduction of CABG and four decades after the introduction of PCI into clinical practice, the procedural and long-term outcomes of the two revascularisation methods are now well characterised. Although technological improvements will continue to increase their safety and efficacy, the relative advantages and disadvantages of the two interventions will probably remain substantially unchanged.

A limitation of available data is that they are from prevalently young, White, male, HIC [high-income countries] populations. The results of coronary revascularisation in women, non-White racial and ethnic groups, older adults, and LMICs [low- and middle-income countries] require further and urgent investigation.

All trials comparing medical therapy, PCI, or CABG aimed at assessing superiority or non-inferiority of one or other strategy in relation to a short list of cardiovascular outcomes (typically death, myocardial infarction, stroke, and repeat revascularisation). Advances in diagnostic techniques have enabled detection of minor non-fatal cardiovascular events, often neither associated with symptoms nor affecting quality of life. There is uncertainty on the definition of clinically relevant non-fatal events (in particular myocardial infarction and stroke) and on how to account for the competing risk of death, and this uncertainty has generated confusion and disagreement in the interpretation of the available evidence. Other events that are very important for patients—such as renal, pulmonary, and neuropsychological outcomes, as well as quality of life and the ability to work and interact socially—have been largely ignored or relegated to secondary analyses. Additionally, trials have generally used a time-to-first-event analysis, ignoring recurrent events and methods to adjust for multiplicity. At this stage of knowledge, the use of a superiority or non-inferiority approach seems outdated, as the interventions used to treat coronary artery disease clearly have very different early and late risk profiles and are complementary rather than antagonistic. The new generation of coronary revascularisation trials should provide adequately powered estimates of the results of the two techniques in heterogenous groups of patients and for a larger number of holistic outcomes, which should not be limited to the cardiovascular system or to the first event only. This information will allow accurately informed treatment decisions based on clinical status and personal expectations and goals to be made by individual patients and their treating physicians.

Finally, some of the classic concepts regarding coronary revascularisation and its role compared with medical therapy might have to be revisited. Future indications for the treatment of coronary artery disease could shift towards less invasive treatments and towards prevention rather than intervention, as generally happens with evolution in medicine.”

Full article, M Gaudino, F Andreotti and T Kimura, The Lancet, 2023.4.27