CABG or PCI for CAD?

Recent years have seen an ongoing debate as to whether heart surgery using coronary artery bypass graft (CABG) or the non-surgical procedure of percutaneous coronary intervention (PCI) is the most appropriate revascularisation strategy for patients with coronary artery disease (CAD), the most common form of cardiovascular disease. During PCI, a cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. X-ray imaging is used to guide the catheter threading. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. This is then combined with stenting, whereby a short-wired mesh tube (or stent) is placed at the site of blockage to permanently open the artery. In patients treated with PCI, improvements in technology and antiplatelet therapy coupled with landmark studies have effectively led to the replacement of balloon angioplasty with coronary artery stenting, which is the current preferred method of PCI.

The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) study was conducted with the intention of defining the specific roles of each therapy in the management of de novo three-vessel disease or left main CAD. Interim results after 12 months show that PCI leads to significantly higher rates of major adverse cardiac or cerebrovascular events compared with heart surgeryusing CABG (17.8 versus 12.4; p=0.002), largely owing to increased rates of repeat revascularisation. However, CABG was much more likely to lead to stroke. Interestingly, categorisation of patients by severity of CAD complexity according to the SYNTAX score has shown that there are certain patients in whom PCI can yield results that are comparable to, if not better than, those achieved with CABG.  

For the practitioner, the most important message to take away from the SYNTAX study is that patients with three-vessel disease should no longer be treated using a generalised approach, but rather should undergo a careful clinical evaluation and comprehensive assessment of CAD severity, alongside application of the SYNTAX score. This will help practitioners in selecting the most suitable therapy for each individual CAD patient and optimise outcomes for this most common form of cardiovascular disease.