Selection of surgical or percutaneous coronary intervention provides differential longevity benefit.
BACKGROUND
Treatment of coronary artery disease (CAD) is evolving with better medications, improvements in percutaneous coronary intervention (PCI), and enhanced techniques for coronary artery bypass grafting (CABG).


METHODS
In this study, 18,481 patients with significant (>75% stenosis) CAD treated at a single center between 1986 and 2000 were assigned to one of three groups based on initial treatment strategy: medical therapy (MED) (n = 6862), PCI (n = 6292), or CABG (n = 5327). Each group was categorized into 3 groups according to baseline severity of CAD: low-severity (predominantly 1-vessel), intermediate-severity (predominantly 2-vessel), and high-severity (all 3-vessel), and prospectively evaluated in Cox models for all-cause mortality adjusted for cardiac risk, comorbidity, and propensity for selection of a specific treatment. Treatments were compared for the entire period and three eras (1: 1986 to 1990; 2: 1991 to 1995; 3: 1996 to 2000), the last encompassing widespread availability of PCI with stenting.


RESULTS
Survival significantly improved in all groups for all degrees of CAD, despite increasing severity of illness. Revascularization strategies provided significant survival over MED with 8.1, 10.6, and 23.6 additional months per 15 years of follow-up for low-severity, intermediate-severity, and high-severity CAD, respectively. Therapeutic improvements led to increased survival of 5.3 additional months per 7 years of follow-up (95% confidence interval, 0.2 to 10.2; p = 0.039) in era 3 for CABG compared with PCI for high-severity CAD.


CONCLUSIONS
Initial revascularization strategies result in significant survival advantage over MED for all CAD levels. Patients with high-severity CAD have reduced survival with PCI compared with those initially treated with CABG.
Smith
Peter K
PK
Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA. smith058@mc.duke.edu
Califf
Robert M
RM
Tuttle
Robert H
RH
Shaw
Linda K
LK
Lee
Kerry L
KL
Delong
Elizabeth R
ER
Lilly
R Eric
RE
Sketch
Michael H
MH
Peterson
Eric D
ED
Jones
Robert H
RH
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D001026:Coronary Artery Bypass; D023921:Coronary Stenosis / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
D002317:Cardiovascular Agents