There is continued debate whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) should be the preferred treatment for nondiabetic patients with multivessel coronary artery disease (CAD) and stable ischemic heart disease (SIHD). A paper published Nov. 16 in JACC: Cardiovascular Interventions looks at both sides of the debate. 

Pranav Kansara, MD, MS, FACC, Sandra Weiss, MD, FACC, and William S. Weintraub, MD, MACC, of the Christiana Care Health System in Newark, DE, defend the existing guidelines, which calls for CABG as the preferred treatment for these patients. Using data from the SYNTAX and ASCERT trials, the group writes that the clinical outcomes of CABG are superior to PCI in nondiabetic patients with three-vessel CAD and SIHD by reducing rates of revascularization, major adverse cardiac or cerebrovascular events and myocardial infarction, while also being more cost-effective than PCI.

Meanwhile, in support of PCI, Matthew C. Hann, MD, and James Tcheng, MD, FACC, from the Emory University School of Medicine in Atlanta, GA, write that there are limitations to the guidelines favoring CABG over PCI. They explain that the rapid and ongoing evolution of PCI renders PCI-specific outcomes outdated before being considered during the creation of guidelines. They add that it is difficult to apply general guidelines to individual patients and argue that findings from previous trials cannot be applied to all patients and find that a PCI-first strategy may be appropriate. They emphasize that it is crucial to choose the right strategy for the right patient.

In conclusion, Lloyd W. Klein, MD, FACC, a member of ACC’s Interventional Council, explains that this debate is “a direct consequence of how guidelines are developed and interpreted.” He adds that future guidelines should avoid making strong recommendations and instead “must do a better job of simulating the decision-making process, defining elements that appropriately influence the application of the recommendation, and acknowledging ‘gray zones.’” 

Keywords: Coronary Artery Bypass, Coronary Artery Disease, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention

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