Complete Revascularization Found to Improve Outcomes After CABG or PCI

Complete revascularization (CR) was associated with significantly lower morbidity and mortality compared with incomplete revascularization, according to a meta-analysis published June 4 in the Journal of the American College of Cardiology.

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The meta-analysis included the results of 35 observational studies and randomized clinical trials that included 89,883 patients with multivessel coronary artery disease treated by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), and showed a 30 percent reduction in long-term mortality (p <0.001), a 22 percent reduction in myocardial infarction (MI) (p = 0.001) and a 26 percent reduction in repeat coronary revascularization procedures (p <0.001). The lower mortality rate associated with complete revascularization was seen in both PCI-treated and CABG-treated patients. The reductions in MI and repeat revascularization associated with complete revascularization were seen in PCI-treated patients but not CABG-treated patients.

The study also found that complete revascularization was achieved most often with CABG than with PCI and that complete revascularization provided clinical outcome benefits versus incomplete revascularization regardless of how it was defined, whether anatomically or physiologically.

"The findings of this study have several practical implications for cardiologists and surgeons alike," wrote the authors. "First, given the strong clinical benefit in patients with multivessel disease, [complete revascularization] may be the optimal revascularization strategy. The likelihood of achieving CR with either revascularization modality, ideally estimated by a heart-team approach, should influence the decision to proceed with CABG or PCI."

The authors suggested that complete revascularization may improve clinical outcomes by reducing myocardial ischemia, improving exercise capacity, reducing the risk of arrhythmic events and improving the patient's tolerance to future acute coronary ischemic events.

In an accompanying editorial, Dean J. Kereiakes, MD, FACC, wrote, "… as CR appears to confer a survival advantage, objective assessment(s) of the completeness of revascularization should be incorporated into procedural quality/performance metrics as well as criteria for appropriate utilization."

He further suggests that a standardized consensus definition of complete revascularization that incorporates both anatomic and physiologic data should be developed to enhance clinical trial analyses in the future.

Keywords: Coronary Artery Disease, Myocardial Infarction, Coronary Artery Bypass, United States, Percutaneous Coronary Intervention

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