Multivessel coronary artery disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Joanna J. Wykrzykowska, MD [2]; Robert Sperling, MD; Brian Bigelow, MD; Roger J. Laham, MD [3]

See also the chapter on Chronic stable angina revascularization

Overview

Multi-vessel coronary artery disease (CAD) is a disease stage in which at least two or three of the epicardial coronary arteries is involved with atherosclerosis of significant severity. Multivessel disease is often associated with a higher burden of comorbidities, left ventricular dysfunction, and cardiovascular risk. In general, PCI is preferred in patients with single or low risk two vessel disease. In contrast, coronary artery bypass graft surgery is recommended in patients with complex two vessel disease, three vessel disease and in some cases of isolated left main disease. Diabetics with left anterior descending coronary artery disease may benefit more from coronary artery bypass surgery. The goal in the treatment of multivessel disease is to reduce angina and heart failure symptoms and to reduce a patient's subsequent risk of adverse cardiovascular events.

Medical Therapy

Medical therapy consists of antianginal and antiplatelet medications as well as high dose statins. All patients, whether they undergo PCI, CABG or not, should receive optimal medical therapies to reduce cardiovascular event-risk and angina. Patients with lower-risk, stable CAD may be effectively treated by medical therapy. Medical therapy has no procedural risk or prolonged convalescence, but the COURAGE Trial[1] showed an increased risk of angina and a decreased quality of life in patients treated with medical therapy. Moreover, 30% of the patients treated with medical therapy eventually needed revascularization. Approximately 2/3 of the study population in COURAGE had multi-vessel CAD, and randomization to an initial strategy of medical therapy resulted in similar rates of death and myocardial infarction (MI) to an initial strategy of PCI.

Revascularization Utilizing Coronary Artery Bypass Grafting (CABG)

When compared to medical therapy and percutaneous coronary intervention, CABG is associated with a lower incidence of recurrent angina and a lower need for repeat revascularization. It reduces late cardiac mortality in diabetic patients who received at least 1 internal mammary (IMA) graft. The rate of revascularization may be comparable in the era of drug eluting stents, but the definitive results of ongoing trials are pending.

CABG Versus Medical Therapy

Recommendations are limited by the quality of data. For instance, older trials of CABG vs. medical therapy had little use of an IMA conduit (which has greater durability) and limited use of ASA, ACE inhibitors, and statins. Several randomized trials of CABG versus medical therapy support the concept of greater absolute benefit associated with CABG with respect to long-term survival in patients with more extensive or proximal CAD, or in patients with impaired left ventricular function. These older data are limited by low usage of internal mammary artery (IMA) grafting, antiplatelet agents, and a high cross-over of the medical treatment arm to CABG. CABG offers survival benefit in patients with left main stenosis, multivessel disease and LV systolic dysfunction, 3-vessel disease with proximal LAD stenosis regardless of left ventricular function, and 2-vessel disease and LV systolic dysfunction, especially with proximal disease and severe angina.

CABG Versus PCI

Many PCI vs. CABG trials did not have widespread use of stents (either bare metal or drug-eluting) or GP IIb/IIIa inhibitors, and <10% of patients who were screened for trials of PTCA vs. CABG were actually randomized, and therefore represent a highly select population. With multivessel stenting, the target lesion revascularization (TLR) rates become cumulative. Diabetics with both retinopathy and nephropathy appear to have very high major adverse cardiac events (MACE) rates with PCI (up to 50%).

Revascularization by Percutaneous Coronary Intervention (PCI)

PCI Versus Medical Therapy

The subgroup analysis of patients with stable, multi-vessel CAD in the COURAGE trial suggested no difference in death and MI rates between PCI- and medically-treated groups.

PCI Versus CABG

One must be confident in their ability to achieve complete revascularization with PCI when offering it as an alternative to CABG.

Mortality and MI

Mortality and nonfatal MI rates are not significantly different between the two strategies. The BARI trial showed similar 5-year survival among over 1800 patients randomized to an initial strategy of PTCA or CABG for multi-vessel CAD, despite the higher rates of “complete revascularization” in the CABG arm. This trial preceded the use of drug eluting stents.

Recurrent Revascularization

There are higher rate of recurrent angina and repeat revascularization after PCI (most trials in low-risk patients with 2-vessel disease and normal left ventricular function); this may change in future with the evolution of drug eluting stents. In BARI, CABG was associated with a lower rate of repeat revascularizations.

Symptom Relief

CABG has been associated with a greater relief of anginal symptoms.

Costs

  • In comparison to CABG, PCI is less invasive, has a shorter hospital stay and convalescence, and has a less expensive initial hospital stay. However, the cost advantage may be lost over the long-term due to the potential need for repeat revascularization.

Trial Results

The ARTS and SYNTAX trials showed higher primary event rates in patients randomized to PCI versus CABG, driven by a higher need for revascularization. Rates of hard events, such as death and MI, were similar between the treatment groups.

Several trials (ARTS I, MASS II, ERACI-II, AWESOME) involving bare metal stents compared to CABG have shown similar survival rates but higher revascularization rates among patients with bare metal stents at 5 years. The SYNTAX trial, a randomized trial of multi-vessel or left main CAD to CABG or paclitaxel-eluting stents, showed higher primary adverse event rates in the PCI group (17.8% vs. 12.4% for CABG; p=0.002), largely due to an increased rate of repeat revascularization (13.5% vs. 5.9%, p<0.001).

Selecting a Therapeutic Strategy or Strategies

Optimal Medical Therapy

Scenarios Favoring CABG Over Medical Therapy to Prolong Survival

Scenarios Favoring PCI over CABG

Scenarios Favoring CABG over PCI

A collaborative analysis of data from 10 randomized controlled trials (N= 7812) was pooled to compare effectiveness of CABG with PCI in view of long term effects on mortality in various clinical subgroups. PCI was done with balloon angioplasty in six trials and with bare metal stents in four trials. The results showed that the long term mortality is similar with PCI and CABG in most patient subgroups who had multivessel disease. Based on this, the choice of the procedure should be made depending on patient's preference for other outcomes. CABG proved a better option in diabetics and elderly over 65 years.[2]

Scenarios Favoring a Hybrid of CABG and PCI

Technical Considerations in the Performance of Multivessel PCI

  • One may need to stage the procedure because of contrast load and radiation dose, as well as procedure time.
  • Starting with the most challenging lesion in patients for whom CABG is an option, may be advisable to evaluate feasibility of complete revascularization.
  • Assessment of patient’s ability to comply with lifetime dual antiplatelet therapy is also crucial especially with bifurcation stenting, long lesions and small vessels, which are common in patients with multivessel disease where risk of stent thrombosis is highest.

References

  1. Boden WE, O'Rourke RA, Teo KK; et al. (2007). "Optimal medical therapy with or without PCI for stable coronary disease". N. Engl. J. Med. 356 (15): 1503–16. PMID 17387127. doi:10.1056/NEJMoa070829.  Unknown parameter |month= ignored (help)
  2. Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM; et al. (2009). "Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials.". Lancet. 373 (9670): 1190–7. PMID 19303634. doi:10.1016/S0140-6736(09)60552-3.  Review in: Ann Intern Med. 2009 Jul 21;151(2):JC1-8, JC1-9

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