PCI vs CABG

Background

Patients and physicians typically have two treatment choices for obstructive coronary artery disease: percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Both treatments have demonstrated efficacy in treating the condition, but there are significant distinctions between them.

Coronary artery disease (CAD) is extremely common in heart failure patients, accounting for two-thirds of all instances. Percutaneous coronary intervention, a series of minimally invasive procedures is used to open clogged coronary arteries, is often used in heart failure patients with CAD and has increased significantly, as it has been linked to improved outcomes in multiple observational studies.1

CABG is another commonly performed operation, with approximately 200,000 procedures performed in the United States each year. However, CABG is a complex and high-risk operation that carries significant risks.2

CABG vs PCI Imaging

Advancements in imaging techniques, including computed tomography, magnetic resonance imaging, intravascular ultrasound, and optical coherence tomography, have improved the detection of patients’ needs for PCI vs CABG interventions. Accurate diagnosis, risk assessment, and appropriate choice of treatment are of utmost importance, because coronary artery anomalies (prevalent in 1% of the general population), ischemia-related symptoms, and arrhythmias lead to an increased risk of sudden cardiac death.3 There are currently many diagnostic methods being developed to improve the accuracy of differential diagnosis of such conditions.

Though researchers have recorded many patterns in the presentation of conditions needing PCI vs CABG, research has also shown a lack of awareness of some atypical, high-risk electrocardiogram (ECG) patterns that may need treatment with the primary PCI method. Up to 10% to 25% of acute coronary syndrome (ACS) patients needing immediate reperfusion treatment may have abnormal ECG rhythms. This varied, high-risk patient group is a challenge for doctors and paramedics, particularly in prehospital care.

Selection

Non-ST-elevation myocardial infarction (NSTEMI) is a large contributor to mortality rates of patients discharged from the hospital after diagnosis of multivessel coronary artery disease. NSTEMI patients are often elderly, comorbid, and have a significant risk of multivessel coronary artery disease (MVD), which is linked to poor clinical outcomes. Unfortunately, there is a current lack of treatment strategies for MVD in NSTEMI, especially treatments related to PCI.8

When comparing treatment outcomes for NSTEMI and MVD in PCI vs CABG, patients with three-vessel or left main disease have shown a lower incidence of death, stroke, myocardial infarction, or revascularization with CABG treatment compared with those who underwent PCI. But, in further research, CABG treatment has resulted in no comparative mortality benefit and has been associated with the patient’s higher incidence of stroke. Though overall, PCI appears to be a viable alternative to CABG in a large proportion of patients with NSTEMI and MVD, the lack of comparative data still leaves unanswered questions.8

Multivessel PCI has been increasingly used as the revascularization strategy in acute myocardial infarction (AMI) and shock. Hospitals that use multivessel PCI more, however, especially among patients with STEMI, tend to have worse outcomes than those that do not. These results could suggest harm caused by this strategy, and according to researchers, there appears to be an urgency to change practice and improve outcomes in this high-risk AMI population.9

In other cases of patients with multivessel coronary artery disease (MVCAD) who have gone through CABG or PCI treatment, mortality rates have been shown to go down with CABG treatment more substantially than with PCI.10

PCI vs CABG Complications

Though CABG has traditionally been the primary intervention for multivessel CAD with associated left ventricular systolic dysfunction (LVSD) for many years, PCI in patients with acute and chronic heart failure with reduced ejection fraction (HFrEF), as well as heart failure with preserved ejection fraction (HFpEF), has recently been introduced.1 There are also currently multiple medications available for HFrEF management.12

PCI or CABG treatment carries a high risk of periprocedural complications, for which there are a number of predictors. The general characteristics of patients were examined in a study in Krakow, Poland, including concomitant diseases, past cardiovascular procedures, gender and age according to PCI of SVG and IMA.13

According to this and previous research, the most serious adverse events that may occur with CABG are death, stroke, bleeding requiring further surgery, peri-operative myocardial infarction, cardiac arrhythmias, and deep sternal wound infection. It is therefore important to discuss these possible risks with a patient during the consent process.2

The greatest differences in the incidence of periprocedural complications (because of the similarity of PCIs performed on internal mammary arteries compared to native coronary arteries), were noticed in patients undergoing PCIs of saphenous vein grafts (SVGs). These included an increased rate of all periprocedural complications, no-reflows, and perforations.

Risk of periprocedural complications are often limited to more specific factors: these include clinical presentation of CAD, TIMI flow before PCI, use of thrombectomy, and gender. Furthermore, a patient is considered more at risk of complications if they have comorbidities such as diabetes, kidney failure, or hypertension.13

Monitoring

Awareness of potential concerns, as well as thorough attention to equipment positioning and patient monitoring, can help to reduce the likelihood of difficulties and allow for rapid treatment if dangers arise. Today, there are devices that can be used in conjunction with artificial intelligence techniques as an effective form of monitoring patients with heart diseases.

Implementing technology could help reduce the number of visits to hospitals and improve patients’ quality of life. There are often no symptoms until a heart attack occurs in patients with heart disease, therefore emphasis on the increased use of remote health diagnosis and monitoring systems to predict, prevent, and monitor heart emergencies is needed.14

References

  1. Parikh PB, Bhatt DL, Bhasin V, Anker SD, Skopicki HA, Claessen BE, Fonarow GC, Hernandez AF, Mehran R, Petrie MC, Butler J. Impact of percutaneous coronary intervention on outcomes in patients with heart failure: JACC state-of-the-art review. Journal of the American College of Cardiology. 2021 May 18;77(19):2432-47. 10.1016/j.jacc.2021.03.310
  2. Hussain SM, Harky A. Complications of coronary artery bypass grafting. International journal of medical reviews. 2019 Mar 15;6(1):1-5. 10.29252/IJMR-060101
  3. Kastellanos S, Aznaouridis K, Vlachopoulos C, Tsiamis E, Oikonomou E, Tousoulis D. Overview of coronary artery variants, aberrations and anomalies. World journal of cardiology. 2018 Oct 26;10(10):127. 10.4330/wjc.v10.i10.127
  4. Tzimas G, Antiochos P, Monney P, Eeckhout E, Meier D, Fournier S, Harbaoui B, Muller O, Schläpfer J. Atypical electrocardiographic presentations in need of primary percutaneous coronary intervention. The American journal of cardiology. 2019 Oct 15;124(8):1305-14. 10.1016/j.amjcard.2019.07.027
  5. Alizadehsani R, Abdar M, Roshanzamir M, Khosravi A, Kebria PM, Khozeimeh F, Nahavandi S, Sarrafzadegan N, Acharya UR. Machine learning-based coronary artery disease diagnosis: A comprehensive review. Computers in biology and medicine. 2019 Aug 1;111:103346. 10.1016/j.compbiomed.2019.103346
  6. Abdar M, Książek W, Acharya UR, Tan RS, Makarenkov V, Pławiak P. A new machine learning technique for an accurate diagnosis of coronary artery disease. Computer methods and programs in biomedicine. 2019 Oct 1;179:104992.
  7. Pastore MC, Mandoli GE, Contorni F, Cavigli L, Focardi M, D’Ascenzi F, Patti G, Mondillo S, Cameli M. Speckle tracking echocardiography: early predictor of diagnosis and prognosis in coronary artery disease. BioMed Research International. 2021 Feb 2;2021. 10.1155/2021/6685378
  8. Baumann AA, Mishra A, Worthley MI, Nelson AJ, Psaltis PJ. Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine. Therapeutic Advances in Chronic Disease. 2020 Jun;11: 10.1177/2040622320938527
  9. Khera R, Secemsky EA, Wang Y, Desai NR, Krumholz HM, Maddox TM, Shunk KA, Virani SS, Bhatt DL, Curtis J, Yeh RW. Revascularization practices and outcomes in patients with multivessel coronary artery disease who presented with acute myocardial infarction and cardiogenic shock in the US, 2009-2018. JAMA Internal Medicine. 2020 Oct 1;180(10):1317-27.  10.1001/jamainternmed.2020.3276
  10. Mulukutla SR, Gleason TG, Sharbaugh M, Sultan I, Marroquin OC, Thoma F, Smith C, Toma C, Lee JS, Kilic A. Coronary bypass versus percutaneous revascularization in multivessel coronary artery disease. The Annals of Thoracic Surgery. 2019 Aug 1;108(2):474-80. 10.1016/j.athoracsur.2019.02.064
  11. Hu CS, Wu QH, Hu DY, Tkebuchava T. Treatment of chronic heart failure in the 21st century: a new era of biomedical engineering has come. Chronic Diseases and Translational Medicine. 2019 Jun 1;5(02):75-88. 10.1016/j.cdtm.2018.08.005
  12. Marti CN, Fonarow GC, Anker SD, Yancy C, Vaduganathan M, Greene SJ, Ahmed A, Januzzi JL, Gheorghiade M, Filippatos G, Butler J. Medication dosing for heart failure with reduced ejection fraction—opportunities and challenges. European journal of heart failure. 2019 Mar;21(3):286-96. 10.1002/ejhf.1351
  13. Januszek RA, Dziewierz A, Siudak Z, Rakowski T, Dudek D, Bartuś S. Predictors of periprocedural complications in patients undergoing percutaneous coronary interventions within coronary artery bypass grafts. Cardiology Journal. 2019;26(6):633-44. CJ.a2018.0044/50024
  14. Otoom AF, Abdallah EE, Kilani Y, Kefaye A, Ashour M. Effective diagnosis and monitoring of heart disease. International Journal of Software Engineering and Its Applications. 2015 Jan;9(1):143-56. 10.14257/ijseia.2015.9.1.12

Author Bio

Sydney Murphy is the Associate Editor of HealthDay Physicians Briefing and a freelance science writer based in New York City. You can follow her on Twitter @SydneyLiz_Murph.