Chronic coronary artery disease: drugs, angioplasty, or surgery?

Tailor the treatment to the patient

The cardiovascular community has been studying the effectiveness of percutaneous transluminal coronary angioplasty for about 15 years and coronary artery bypass graft surgery for about 25; yet important questions remain about the relative roles of these two revascularisation procedures in patients with chronic coronary artery disease. A recent meta-analysis comparing angioplasty with bypass surgery1 is most appropriately interpreted in the context of previous trials comparing angioplasty or bypass surgery with medical treatment.

An overview of randomised trials published in 1994 included data on about 2500 patients; it found that bypass surgery resulted in a highly significant overall reduction in mortality compared to initial medical treatment in patients with chronic coronary artery disease.2 This difference in mortality was clearly evident only after four to five years of follow up and was confined to patients at high and moderate risk of death (those with five year mortality during medical treatment ranging from 25% to about 12%, in whom the risk reduction with bypass surgery was 50% and about 37%, respectively.) Patients at low risk of death (those with five year mortality rates of about 5%) were not likely to live longer after bypass surgery.

Two trials have compared medical treatment with angioplasty in patients with single vessel disease.3 4 Neither trial was large enough to detect a significant difference in the major clinical outcomes of death or myocardial infarction. The ACME trial, which included patients with angina and exercise induced ischaemia, …